Rheumatology Services Model of Care_2007_Lakes DHB

RHEUMATOLOGY SERVICES
MODEL OF CARE
2007

Rheumatology Model of Care Report March 20072
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 Page 30
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 meetingTeam meetingTeam meetingTeam meeting
(Core team = rheumatologist, nurse, physio, OT,
counsellor)
CarePlusCarePlusCarePlusCarePlus
Nurse led
clinics &
helpline
OT Comm’y-
based
education
MDT lead
Intensive
Rehab
OrthoticsGP/
CarePlus
Physio PodiatryDieteticsCounsell’g
Health PromotionHealth PromotionHealth PromotionHealth Promotion
HealthPromotionHealthPromotionHealthPromotionHealthPromotion

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
Tokoroa
Murupara
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 Requirements
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 Framework
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 Standards 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 & DMARDs 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 Delivery
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 with rheumatology ICD-10
Code
0
1
2
3
4
5
6
7
Diagnosis
NumberofPatients
rheumatoid arthritis
Gout
Polyarthritis
coxarthrosis
Polyarteritis nodosa
Other giant cell arteritis
Polymyositis
Polymyalgia rheumatica
Unspecified 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 Hospital ICD-10
code athritis as primary diagnosis
Pyogenicarthritis
BursitisG
out
0
1
2
3
4
5
6
7
8
9
10
1
Diagnosis
NumberofPatients
Pyogenic arthritis
Bursitis
Gout
Other primary coxarthrosis
Synovitis & tenosynovitis
Other specified arthritis low er leg
Staph arthritis polyarthritis
Oth strep arthritis polyarthr low er leg
Unspecified spondylosis lumbar region
Synovial cyst of popliteal space [Baker]
Arthritis polyarthr dt oth bact low leg
Rheumatoid arthritis NOS low er leg
Unspecified discitis lumbar region
Other juvenile arthritis low er leg
Other chondrocalcinosis low er leg
Monoarthritis NEC low er leg
Other primary gonarthrosis
Vertebral osteomyelitis thoracolumbar
Trigger finger
Enthesopathy unspecified

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 orthopaedic unit with
rheumatology ICD-10 code
0
10
20
30
40
50
60
70
80
90
100
Diagnosis
Numberofpatients
coxarthrosis
Gonarthrosis
Synovitis, tenosynovitis &
trigger finger
Primary arthrosis
Arthritis 1st
carpometacarpal jt
Rheumatoid arthritis
Seropositive rheum arthr
NOS ankle foot
Gout unspecified ankle and
foot
Arthritis unspecified
shoulder region
Synovial cyst of popliteal
space [Baker]
Adhesive capsulitis of
shoulder
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
Numberofpatients
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 Services
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
Numberofpatients
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)
CarePlusCarePlusCarePlusCarePlus
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
HealthPromotionHealthPromotionHealthPromotionHealthPromotion

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.

Rheumatology Services Model of Care_2007_Lakes DHB

Rheumatology Services Model of Care_2007_Lakes DHB

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