STEPPING UP FOR MĀORI The Asthma Foundation Māori Engagement Strategy Dr Tristram Ingham Ms Cheryl Davies Strategic Advisor Māori Board Member
Introduction Our Vision: Better respiratory health for all New Zealanders Our Goal: Reduce hospital admissions caused by asthma and other respiratory conditions by 25%, by 2025
The Burden of Respiratory Disease 700,000 (individuals with respiratory disease in NZ) $5.5 billion p.a. (direct & indirect costs) 3 rd highest cause of disability (Lung Disease by DALY) 3 rd highest cause of hospitalisations
Respiratory Hospitalisations (Hospitalisations, All DHB’s, 2006 -2011) Non-Māori Māori 6 Standardised Relative Rate ( Māori 5.1 5 4.64 4 vs Non- Māori ) 3 2.48 2.55 2.09 2 1.37 1 0 Asthma Upper Influenza & Other Lower COPD Lung Cancer Respiratory Tract Pneumonia Respiratory Tract Infection Infection Data: Asthma Foundation/ University of Otago 2013
Respiratory Hospitalisations (Hospitalisations, All DHB’s, 2006 -2011) ASTHMA UPPER RESP INFECTIONS INFLUENZA/PNEUMONIA Māori Māori Māori 26% 27% 35% non- non- non- Māori Māori Māori 65% 73% 74% OTHER LOWER RESP INFECTIONS COPD LUNG CANCER Māori Māori Māori 30% 34% 39% non- non- non- Māori Māori Māori 61% 66% 70% Data: Asthma Foundation/ University of Otago 2013
Strategy Aims Explore ways in which the Asthma Foundation can collaborate with Māori health provider networks & communities to improve Māori respiratory health Inform the Asthma Foundation’s strategic direction & responsiveness to Māori policies
Desired Outcomes To enable the Asthma Foundation to establish stronger working relationships with Whānau Ora collectives and Māori health providers to: enable closer, more meaningful collaborations at local and regional levels contribute to improving the access of whānau to services, information and support reduce the burden of respiratory illnesses for Māori.
PROJECT PHASE 1 SCOPING & NEEDS ASSESSMENT
Phase 1 Objectives 1. Meeting the collectives to introduce the Foundation and what it does 2. Outlining its commitment to improving Māori respiratory health conditions 3. Outlining how it intends to carry out that commitment 4. Finding out what collectives are doing in respiratory health , especially for Māori 5. Identifying the gaps and what is working 6. Identifying other areas the Foundation can help with their work in respiratory care
Recommendation One: Continue to build the Asthma Foundation’s relationship with Māori (via Whānau Ora collectives) to: - better understand their specific needs; - raise their awareness of the foundation; and - collaboratively co- develop a Māori respiratory strategy.
Recommendation Two: Investigate and explore innovative resources (e.g. multimedia) that will be of more relevance to Māori communities.
Recommendation Three: Collaboratively develop a Māori respiratory research agenda resulting in improved respiratory health outcomes for Māori . E.g.: - research to improve health literacy; - complimentary methods of respiratory wellness - strategies to mitigate health disparities; and - innovative service delivery models.
Recommendation Four: Collaboratively develop best practice support structures that are responsive and relevant to Māori - to support practitioners working with Māori whānau
Recommendation Five: Understand specific needs of Whānau Ora collectives around workforce training and development and to use these recommendations to broaden and revise the existing Asthma Foundation training programmes.
PROJECT PHASE 2 COLLABORATION & INTERVENTION DEVELOPMENT Bernadette Jones with Cheryl Davies and whānau
Aims To continue to engage with three Whānau Ora collectives To collaboratively develop and pilot ‘ best-practice support’ packages for Māori providers (using tamariki asthma as a development model)
Whānau Ora Collectives Kotahitanga (South Auckland) • Papakura Marae • Te Kaha o Te Rangataki Trust • Turuki Healthcare Trust Ngā Mataapuna Oranga (Tauranga Moana) • Te Manu Toroa Trust • Te Rūnanga o Ngāti Tamawhariua Takiri Mai Te Ata • Pirirākau Hauora Charitable Trust • Te Puna Hauora Ki Uta Ki Tai (Lower Hutt) • Whaioranga Trust • Kokiri Marae Keriana Olsen Trust • Waitaha Hauoranga Charitable Trust • Kokiri Marae Maori Women’s Refuge • Kimioranga Primary Healthcare • Mana Wahine Services • Naku Enei Tamariki • Tū Kotahi Maori Asthma Trust • Wainuiomata Marae • Whai Oranga o Te Iwi Health Centre
Methodology Kaupapa Māori methodology Participatory Action Research (PAR) Plan-Do-Study-Act cycles Act Plan Embedded capacity (Asthma Champions) Study Do
Project Team: AUCKLAND HUTT TAURANGA AF Project Team (Kotahitanga) (Takiri Mai Te Ata) (Nga Mataapuna Oranga) Atareta Arnold (RN) Dr Tristram Ingham Maraea Nathan (RN) Bernadette Jones (RN) Lee Walters (RN) Mr Tu Williams Mrs Janice Kuka Vicky Maiava (RN) Ms Cheryl Davies Dr George Gray
3 Workstreams: Kotahitanga Takiri Mai Te Ata Ngā Mataapuna ( Tāmaki Oranga (Te Awakairangi) Makaurau) (Tauranga Moana) Effective Effective community communication engagement with with whānau in a Effective service Māori rangatahi healthcare delivery for Māori with asthma context with asthma [Rangatahi [Asthma [Data Quality Engagement Resources] Indicators] Strategies]
Workstream 1: Kotahitanga Takiri Mai Te Ata Ngā Mataapuna ( Tāmaki Oranga (Te Awakairangi) Makaurau) (Tauranga Moana) Effective Effective community communication engagement with with whānau in a Effective service Māori rangatahi healthcare delivery for Māori with asthma context with asthma [Rangatahi [Asthma [Data Quality Engagement Resources] Indicators] Strategies]
Background Collectives expressed concerns re difficulties in objectively assessing performance in respiratory health (for Māori) No established indicators of service effectiveness for asthma in primary health (PHO Enrolment, Smoking cessation, ASH) No nationally available comparative data available for benchmarking performance
Atlas of Variation
IPIF Performance Dashboard – Non- Māori
IPIF Performance Dashboard – Māori
Aims: 1. Assess data quality in primary care 2. Refine primary care indicator selection 3. Assess indicators for other steps in the patient journey
Patient Journey Community/ Home Primary Care Hospital Home Quality Diagnosis Pharmaceuticals Admission Rate Heating Education Compliance LOS Specialist Prescribing Education Review Review Spirometry
NICE Quality Standard 25: Asthma (UK, 2013) 11 Quality Statements: 1. Diagnosis 2. Occupational Asthma 3. Written Personalised Action Plans 4. Inhaler Technique 5. Review 6. Assessing Asthma Control 7. Assessing Severity 8. Treatment for Acute Asthma 9. Specialist Review 10. Follow-up in Primary Care 11. Difficult Asthma
Barriers to Reliable Primary Care Indicators Purposive vs. routine data collection Practice Management System (PMS) vs Epidemiological survey (ISAAC, NZHS) Misclassification of ethnicity Patient management systems in primary care have been shown to misclassify the ethnicity of up to 37% of Māori patients. (Bramley 2007) Coding of patient information poor E.g. smoking status was correctly coded in less than 50% of Māori smokers in a 2006 study ( Selak 2006). Incentives New Zealand's PHO Performance Programme incentivised data quality improvement for smoking status for several years before the measure was sufficiently robust for use as a Health Target contributor.
Interview Themes Qualitative Interviews were conducted with Clinic Staff across the three collectives: 1. GP’s and nurses agree asthma management is poor – gaps evidential 2. Diagnosis are loosely guided dependent greatly on clinical judgement 3. No monitoring systems or alerts to prompt or recall asthmatics 4. Very little follow-up contact with asthmatics regardless of severity 5. Asthma education is limited by 15 minute time slots: GP vs Nurse 6. Very few utilise an array of resources 7. Asthma Management Action Plans not considered useful by many 8. Clinical priorities are ‘target’ focused
Methods PMS data were made available from 5 participating medical clinics. Data were extracted by customised Medtech queries and results inspected. Inclusion criterion were: children aged 0-14 years enrolled in participating clinics Māori ethnicity on PMS Asthma was identified by utilising all asthma- related Read Codes [H33…] ( Mukherjee et al. BMJ Open 2014). Comparison was made with New Zealand Health Survey 2013/14 prevalence estimates for Asthma (Māori, 2 -14 years) (i.e. anticipated prevalence of 20.7%) 3,210 children were identified in total 80% were Māori (n=2,552)
Results: Diagnostic Coding Children with Asthma (by NZHS Prevalence Estimate) 38% Coded as 'Asthma' Not Coded as 'Asthma' 62% N = 2,552
Results: Downstream Indicators Provision of asthma education Provision of asthma action plan Review: six-month or one-year < 5 out of 3,210 ( i.e. < 1.5%) Inhaler Technique review Peak flow monitoring
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