An intervention programme initiated by clinical nurse specialist and EIT Master of Nursing student Sara Mason is significantly boosting health outcomes for the many people in Hawke’s Bay diagnosed with respiratory disease.

Working for the Hawke’s Bay District Health Board’s recently-created Pulmonary Long Term Management Service, Sara believes the model could also be used to better manage other health conditions and she sees potential for rolling it out elsewhere in New Zealand.

The customised service prioritises patients according to their assessed health needs while also addressing what they consider to be socially and culturally important.

New Zealand has the second highest incidence of hospitalisations for respiratory disease in the OECD.  One in 15 people over the age of 45 has chronic obstructive pulmonary disease, Sara says, and long-term patients are the biggest users of New Zealand’s health dollar.

For a variety of reasons, Hawke’s Bay’s population is particularly vulnerable.  The region has a high percentage of Māori, and Māori and Pasifika are five times more likely to die from chronic respiratory disease causes than non-Māori.  They also die up to 20 years earlier than for the wider population.

“The biggest indicator for developing respiratory disease is the environment you’re born into,” Sara explains.  “Contributing factors can be smoking, chemicals such as agrichemical sprays, and the disadvantages experienced by those who are in a lower socio-economic group.”

An American, Sara moved to this country nine years ago, attracted by New Zealand’s more affordable nurse education.  Nonetheless, she was shocked to find many New Zealand houses were poorly insulated compared to those in her home state of Idaho, where winters can be very harsh.

Arriving in Invercargill, she, husband Doug and a daughter slept in the living room of their rented accommodation because their bedrooms were so cold.

After Sara’s initial nurse training, they left Southland, checking out hospitals as possible workplaces as they travelled north.  Hawke’s Bay proved a good fit.  Involved in the nurses’ union, Sara had previously attended a hui for nurses hosted on the Omahu marae west of Hastings.

“So I felt connected to Hawke’s Bay and the Ngaruroro River,” she says of the couple’s decision to make this region their home.  “Part of my own culture was that feeling of connection to the land – in Idaho, the land was how you ate.  Hawke’s Bay definitely ticked the boxes.  People greet you here and meet for coffee.  It’s nice.”

Taking on a position with the Hawke’s Bay District Health Board, she initially worked with pulmonary patients as a rehab nurse.  However, services were stepped up when referrals rocketed by 300 percent in just eight months – the result of the HBDHB implementing three new initiatives to detect undiagnosed respiratory disease.

Coping with the increased volume of patients called for a different approach – directing services more efficiently to reduce the risk of hospitalisation, better supporting patient rehabilitation, empowering patients by providing more tailored information and acknowledging the low engagement of Māori in existing health services.  

A new multi-disciplinary service now operates in Napier, Hastings, Flaxmere, Havelock North, Waipukurau and Wairoa, in venues such as local gyms, community centres, patient homes and aged care facilities.  And it links up with whānau, health providers and community services that individual patients feel are important in their lives.

The pulmonary management team works in tandem with community services, general practitioners, Presbyterian Support East Coast’s restorative home support service Enliven, hospital social workers, occupational therapists and specialist physicians in focusing on reducing the need for outpatients’ reporting to the district health board.

This new model builds on findings from a six-month pilot launched by Sara two years ago to determine what difference pulmonary care long-term management had on hospitalisations.  Tracking two categories of patients, Sara then compared these with a control group in a pre-post design.

The pilot recorded an impressive 63 percent decrease in hospitalisation rates and a significant improvement in patients’ ability to complete a six-minute walk test.  Anecdotal results showed better communications within the network of health services dealing with patients and there was a greater uptake with management and crisis plans for those assessed as high risk.

“The idea,” she explains, “was to create a modelled tiered system so we could focus our energies in areas where patients were most at risk while still supporting others so they didn’t end up in the high risk category.”

In developing relationships across primary, secondary and tertiary health providers, the pilot promoted a continuum of care and provided for pulmonary patients who didn’t fit into mainstream services.

Now, with the new model in place, patients referred to the clinic are assigned to one of three groups based on their health needs.  Those in the long-term intervention group are patients requiring ongoing monitoring and the support of primary health services.

Patients considered to be lower risk, having undergone a comprehensive one-hour assessment, receive an individualised treatment plan to help them self-manage their condition and are referred back to their GP with recommendations for their care. 

A further group is trialling a 10-week pulmonary rehabilitation programme.

Sara cites an example of an individualised care programme designed to encompass services and cultural values that patients consider important in their lives.

“One woman who ran a school on her property didn’t want to come to a traditional programme,” she says, “so her programme was integrated into the school’s timetable.  When the children go for a walk, she goes walking too.”

The project’s findings are feeding into Sara’s master’s thesis entitled The effect of long-term care management programme on hospitalisation presentations:  A retrospective three group control study, which she expects to complete by the end of the year.

Delighted that the programme is achieving positive results, she sees potential for similar interventions in other areas of health care, both in Hawke’s Bay and in other health board districts.

“They target high risk patients in other countries,” she says of health interventions overseas.  “The problem I saw here was that we weren’t picking part different interventions to see what is making the difference.

“I feel very passionate and protective about what happens here.”