ࡱ> G @`bjbjَ eZ3]&&&&6 R |&n" Ln ( (6^r nnnnnnn$prxn~|~~nf " fff~8 R n&&~nf fhR`"n TpC&&~4nCommunity Paediatric Service Notes for purchasers January 2006 Executive summary This short paper will define Community Paediatrics and give four examples of local community paediatric services in New Zealand. The core skills of community paediatricians are defined by the guidelines for training of the Royal Australasian College of Physicians Specialist Advisory Committee in Community Child Health. However local services will develop according to local need and opportunity. This paper assumes the reader has a detailed knowledge of the epidemiology of child morbidity and mortality in New Zealand and therefore understands the issues for child health. If not, we recommend you read the following publications from the Ministry of Health: MOH 1998. Our Childrens Health: Key Findings on the Health of New Zealand Children MOH 1998. Child Health Program Review MOH 1998. Child Health Strategy MOH 1998. Through the Eyes of a Child: A National Review of Paediatric Specialty Services. MOH 2005. Child Health Toolkit  HYPERLINK http://www.moh.govt.nz www.moh.govt.nz The paper was originally compiled by Dr Russell Wills, Community Paediatrician in Hawkes Bay and previous Chair of the Community Child and Youth Health Special Interest Group of the Paediatric Society of New Zealand, and has been updated by Dr Alison Vogel, current Chair, with input from Dr Wills, Dr Nick Baker and Dr Giles Bates, Community Paediatricians in Nelson and Palmerston North. Skills of the Community Paediatrician The Royal Australasian College of Physicians defines Community Child Health as involving an understanding of how the interplay between physical and social environmental factors and human biology affects the growth and development of all young people whether well, ill, impaired or disabled. The social environment includes family and school as well as broader social influences, such as the regard given to the rights of children and the policies and laws that affect the life of children and the services provided within a society to promote their developmental health and well being. NOTEREF _Ref7695622 \h  \* MERGEFORMAT 1 The training guidelines of the Royal Australasian College of Physicians SAC Community Paediatrics requires specialist Community Paediatricians to receive training and demonstrate competence in the following domains: clinical practice: including general hospital and outpatient paediatrics, assessment and management of children and young people with developmental, learning and behavioural problems and disabilities, child abuse and neglect, paediatric rehabilitation, child and adolescent psychiatry population medicine: encompassing needs assessment, including the needs of child and adolescent populations with specific needs, community diagnosis, screening and surveillance, infectious disease control, injury control, health program planning, evaluation, and research including the quantitative and qualitative measurement of health outcomes effective health service provision and utilisation: management, communication, team leadership, liaison and referral skills within and across disciplines and relevant government, non-government and private agencies child and adolescent health promotion: through education, information provision, effective use of medicine and other preventive programs and advocacy academic leadership: through participation in teaching, training and research individual professional development through an ability to critically appraise literature, undertake research, demonstrable keyboard and computing skills, and continuing medical and other professionally relevant education knowledge: of government policies, programs and services and their philosophical underpinnings which affect the health of children, particularly those with additional needs. Goals of a community paediatric service To develop and/or implement within a defined population for all children:- a detailed assessment of the health and development needs effective health promotion and health protection programs a comprehensive co-ordinated system of quality child health services that meet identified needs systems for identification, support and reintegration programs for children with "special needs" an integrated framework of services linking health and non-health sectors to achieve maximum support and health gain for children and families systems for monitoring and evaluation of the efficacy, efficiency and community value of child health programs, and of the service as a whole. information systems that use evidence to tailor child health services to meet the changing needs and health outcomes of a community. Participation in, and often leading the Child and Youth Mortality Review system for the DHB. This requires participation in the National Framework for Mortality Review and being appointed as an agent of the national CYMRC. The local group of agents of the CYMRC act asa multi-disciplinary, multi-agencypoint of contact to examine both local and nationalsystems that surround children, making recommendations for improvements to both the local DHB and the Minister of Health through the National CYMRC. See  HYPERLINK "http://www.newhealth.govt.nz/cymrc" \o "http://www.newhealth.govt.nz/cymrc" www.newhealth.govt.nz/cymrc "One model of the population health role of community paediatrics sits within a conceptual model of Health Promotion. That model considers three overlapping elements: Health Education, Health Protection, and Disease Prevention. Community Paediatricians are placed within the disease prevention sphere, and using the intertwined knowledge, skills and resources and knowledge of health education and health protection, to achieve their goals. Disease prevention includes primary prevention (expressed as prevention of child and youth morbidity and mortality), secondary prevention (which encompasses elements of both screening and surveillance, and the function of early detection of child and youth morbidity and mortality, or potential for this) and finally tertiary prevention (which covers the scope of systems for management of existing morbidity, at both the individual and group level. As a case example, one of the roles of the Community Paediatrician is in relation to childhood obesity. Operationally, the community paediatrician's role is first to undertake a needs assessment (identifying whether there is a problem and it's order of magnitude), and to evaluate the risks and benefits of developing and implementing a response. Prevention and treatment programmes may then be developed, implemented and evaluated. This requires multi-agency, intersectorial and multidisciplinary work, utilising a skill-set that includes Health Education and Health Protection. Much of the required work cannot be done by the Community Paediatrician in isolation, but they may act as a catalyst and/or leader, maximising the potential contribution of others with appropriate skill sets." The Paediatric Society of New Zealand submission to the Tertiary Services Review recommended that, based on UK standards for Community Paediatric Services, Each district should have a designated person or group that provides local community paediatric services. As a guide 1 FTE (excluding registrar posts) should initially be employed for every 66,000 population age 0 - 19 years. (Approx. 1 FTE per 200,000 population depending on age structure.) NOTEREF _Ref7695240 \h  \* MERGEFORMAT 2. Currently (December 2005) we are aware of dedicated paediatric tenths for community paediatrics in Northland, West and South Auckland, Waikato, Hawkes Bay, Bay of Plenty, Palmerston North, Tairawhiti, Nelson Marlborough and Christchurch. Examples of Community Paediatric services in New Zealand Nelson Marlborough Nelson-Marlborough employs a community paediatrician, Dr Nick Baker, who has approximately 0.4 for local community paediatrics (population child health work). Dr Baker is also employed as a general paediatrician for the region. Over the years it has proved very important to have clearly defined time for the community paediatric work. There is a constant trend for clinical work involved in personal health care to grow to fill all employed hours. By having days with no clinical responsibility this trend has been reduced. The general paediatric and community roles complement each other. Direct involvement in personal health care allows much greater understanding of current issues and problems that require population based interventions. The overall goals of the community paediatric service in the region are included as Appendix 1. There are three major arms to the community paediatric work in Nelson-Marlborough: 1. Basic work within the community to improve local service delivery for children by training, planning, care pathway development, and participation in and development of multidisciplinary teams. Public Health, the PHO, Funding and Planning and Mori providers also do this type of work. It has been very important to work closely with these groups. The work is done by all paediatricians although the bulk is done by the community paediatrician. Current activities include work with several community agencies including: Early Intervention Team Strengthening families steering group Child and Adolescent Mental Health Services General Practitioners/ Primary health organisations Plunket Public health nurses Local Territorial Authorities Health promoters Health Protection Officers Midwives Support for community hospitals Group Special Education Schools Iwi Providers The Media Project work to address specific causes of childhood mortality and morbidity. Specific project work aims to provide a catalyst and a framework for child health activities across all levels of the community. For instance although dental caries was the commonest disease in children in the region and many people were working to address the problem they were not working together. By developing a specific project team it has been possible share knowledge, concentrate expertise and plan future interventions together. Extensive community paediatrician time is needed in the early phases of each project and then less specialised workers are needed to sustain each project. An information system has also been developed to target the projects and study their impact. The newly developed Child and Youth Epidemiology Service has this year provided a detailed report to guide local strategic planning and funding. Current projects (2005) DHB Child and Youth Advocacy and Expert Advisory Reference Group http://www.nmdhb.govt.nz/publisheddocs/index.shtml#child Meningococcal programme and NIR Dental project Team Breastfeeding Network Smoke-free Project Team Well Child Steering Group Physical activity and Nutrition team Green prescription pilot Carer support group Special Nelson Asthma Project Child Abuse Family Violence DHB Working Group Strengthening Families Management Group General Practitioner Guidelines Work Youth matters committee NCC Injury prevention- Kidsafe coalitions Youth Suicide Groups Obstetric audit committee Policy and planning secondary care Development of Child and Youth Mortality Review 3. Liaison with National and International Groups. Community paediatrics cannot be practised in isolation from national bodies, as many of the factors influencing local child health are determined nationally. In addition much can be learnt from the impact of programs in other communities. Much of the work in Nelson has been innovative creating considerable national interest with requests for involvement in meetings, committees and publications outside of the region. Counties Manukau DHB CMDHB/ South Auckland Health has employed community paediatricians since 1999. A number of clinicians have shared components of community paediatric work. Community paediatricians have combined clinical work with dedicated population health time. Since 2003 there has been a community fellow position providing training in population child health, comprising half time clinical workload and half time academic study/ research project work. Multidisciplinary support functions include support for Home care nursing service Public health nursing Child development service Family options There is a significant education and training function for the community fellow, ambulatory registrars and medical officer. Project work of various people includes involvement and liaison with DHB child strategic plan School health stocktake Special Schools disability project Well child steering group Meningococcal implementation Kidslink/NIR Child Oral Health project Lets Beat Diabetes Kids in Action obesity interventionAIMHI schools NEW (Nutrition, Education Weight) Project AIMHI schools NEW (Nutrition, Education Weight) Project Healthy Housing Project Paediatric epidemiology service Hospital Child Mortality review Guidelines development and implementation across primary and secondary care B4 Baby breastfeeding support project Child Disability allowance access project National roles include Chair CCYH SIG Baby Friendly community Initiative working party Midcentral DHB Midcentral DHB has identified Community Child Health as a priority area and have guaranteed funding for a stand alone Community Paediatric Service. The project has a full-time Project Managerand the service started functioning in January 2006, initially with: 0.3 FTE Community Paediatrician 0.5 FTE Social Work 0.5FTE Health promotion There is the potential for expansionand the Community Paediatrictime should be at least 0.5FTE by the end of 2006. The Community Paediatric Servicehas a focuson working collaboratively with agencies/ health providers. The areas for development are: Population Health Child Health advocacy through the Child Health Portfolio Manager (appointedMay 2006) andthe establishment of Child and Youth Health Reference and Advocacy Group Co-ordination of Community Services and improved linkages Education of Primary Health Care Providers Development ofa community wide project in a high needs area Some paediatrician clinic workload Paediatric Nursing projects e.g. Enuresis Establishment of the Child Mortality Review A pilot health assessment of Children in Care, run in conjunction with Child, Youth and Family Development of community Child Abuse and Child Sexual Abuse guidelines and clinics. Hawkes Bay District Health Board HBDHB has employed a general and community paediatrician with approximately 0.5FTE for community child health since 2002. Of this, 0.2 FTE is spent in specialist developmental and behavioural and child protection clinical work, particularly assessing children with the developmental and behavioural effects of abuse and neglect. Population child health projects occupy 0.3 FTE. The community paediatrician is supported by 0.5 FTE Family Violence Intervention Programme Coordinator 0.6FTE Child Protection Programme Coordinator Developmental Assessment Programme (multidisciplinary assessment service for children suspected of ADHD or Autistic Disorders) Analyst support as required. The HBDHB Public Health Physicians and Public Health Nurses have a strong interest in child health and work in close collaboration, e.g., in Health Promoting Schools and Child Injury Prevention. Senior management support has also been critical in the achievements of the community child health programmes to date. Community Child Health achievements at HBDHB to date include: Reduction of admissions to the Childrens Ward of 20% Successful implementation of MeNZB and National Immunisation Register Over 900 staff trained in dual assessment of child abuse and domestic violence Increased referrals to Child, Youth and Family of seven times and identification of domestic violence increased by three times Reduced mean age at diagnosis for children with autistic disorders Workforce development programme for Resource Teachers Behaviour and Learning, with improved referrals and Individual Education Plans Closer working relationships with CYFS, Special Education, Police and NGO sector Child Health Service Strategic Plan in place for three years Annual Child and Youth Health Status Report, which guides all purchasing and service planning Reduced child injury admissions. Current projects include Joint research programme with Otago University aiming to reduce preschool injuries in the home Hawkes Bay Family Violence Prevention Strategy, an intersectoral, multi-agency approach to prevention of family violence The Journey to 2015, a major planning exercise across HBDHB Community Asthma Project, implementing the New Zealand Asthma and Wheezy Baby Guidelines in the hospital and general practice Screening for Congenital Sensorineural Hearing Loss Publication of the various evaluations of the above programmes. What helps to make regional community paediatrics effective? In our experience the following are helpful ingredients for success in regional community paediatrics: Supportive infrastructure: The Community Paediatrician needs a supportive infrastructure of staff, with designated individuals to take on the role of sustaining and implementing projects as well as clerical support. Clear support at senior management level is frequently necessary to sponsor projects requiring significant organisational change. Sub contracts for IT, conference organising and evaluation need to occur at times. Clinical role: a clinical component is very helpful to give credibility to the role. In New Zealand most community paediatricians are also general paediatricians, with a commitment to the acute roster. However a clear division of clinical from community paediatric time is vital to prevent community work from being disrupted by clinical pressures. Relationship with DHB strategic planning and funding teams. Joint working with DHB public health physicians is very useful. Accountability: It is appropriate to set key performance indicators (KPIs) for the Community Paediatrician, but these deserve careful thought. A settling in period is critical to allow the community paediatrician to form local networks. The first few months may appear non-productive as relationships are established and joint plans formed; however without this time plans will be unlikely to be supported by groups in the community. We suggest a monthly narrative report initially, describing the broad goals, what has been achieved and the work plan for the coming month. In time specific projects with measurable objectives will become clear and can be included in the Community Paediatricians KPIs. National projects: Work at national level has been instrumental in achieving funding for local community paediatric services, however a balance has to be retained between national and local project work. In the future these national links may lead to new opportunities for funding. Professional supervision: The work can be stressful and, at times, progress can appear to be slow and frustrating. It is helpful for the community paediatrician to have ready access to senior colleagues for support and guidance, both locally and nationally. Regular meetings with others working in population child health are helpful to share knowledge and ideas. Opportunities for this are available through the Child and Youth Health Special interest Group of the Paediatric Society NZ. Teaching: Teaching and provision of training opportunities can be time consuming but also allow for reflection on ways to improve service provision. Alison Vogel Chair Community Child and Youth Health Special Interest Group Paediatric Society of New Zealand ALVogel@middlemore.co.nz Appendix 1 Functions of Community Child and Youth Health Services. (NMDHB) Aim TO: Improve the health status of children and young persons within the Nelson Marlborough region. Strategic Planning TO: Undertake population-based strategic planning for improving child and youth health status. TO: Obtain detailed assessment of the health and development needs. TO: Use information systems to produce evidence to tailor child health services to meet the changing needs and health outcomes of our community. Integration Process TO: Promote, facilitate co-ordinate and manage the process of integrating health service delivery including effective health promotion and health protection programs throughout the region and beyond. TO: Undertake any activity or function, which is consistent with management of the integration process. TO: Develop an integrated framework of services linking health and non-health sectors to achieve maximum support and health gain for children and families Relationships TO: Foster and facilitate effective relationships between child and youth service providers, voluntary organisations, iwi and consumer groups from all sectors. Integration Initiatives (e.g. projects, programmes, pathway development, guidelines, multidisciplinary teams etc) TO: Encourage, facilitate and assist the development and implementation of integration initiatives. TO: Advise the DHB on funding and other resources to assist integration initiatives. TO: Ensure that any systems created are jointly developed and simple to use. Resource Utilisation TO: Promote, encourage, facilitate and assist initiatives which seek to:- improve the efficiency and effectiveness of resource utilisation and service delivery eliminate service duplication encourage best practice and/or evidence based practice achieve health gain targets Contracting Strategies TO: Collaborate with the District Health Board to ensure that:- contracting strategies are appropriately targeted to achieve population health gain targets incentives are aligned perverse incentives are eliminated Publicity & Public Relations TO: Create an appropriate local and national profile for the integration process TO: Promote, publicise, raise public awareness and keep people informed of the integration process TO: Ensure that people who should know do know Research & Analysis TO: Promote, facilitate and where appropriate manage the development and analysis of child health data to provide accurate information, evidence of need, influence funding decisions, establish health gain priorities and monitor outcomes of initiatives taken Monitoring & Evaluation TO: Ensure that: integration initiatives properly planned, executed, monitored and evaluated. action is taken on information arising from monitoring, evaluation and research Intersectoral Collaboration TO: Promote and facilitate: intersectoral collaboration opportunities for the non-health sector to contribute to health gain the elimination of unnecessary service duplication of health-related services in the non-health sector Workforce Development and Standards TO: Provide resources and expertise to support organizations in professional development and in-service training. TO: Advise on development and implementation of standards of care.  Royal Australasian College of Physicians 1998. Requirements for Physician Training. Sydney, RACP.  Paediatric Society of New Zealand 1998. Community paediatrics: Tertiary Services Review. Wellington, PSNZ. THE PAEDIATRIC SOCIETY OF NEW ZEALAND Secretariat: Email:Denise Tringham P O Box 22 234 Wellington Tel: (04) 938 4827 Fax: (04) 976 4827 psnz@paradise.net.nz   PAGE 10 of  NUMPAGES 12 Health of our children: Wealth of our nation ACU&'(78  4 5 M N ^ _ ` a b c ; N Yk#8qNV$%' 2LM_!!"!:!;!K!L!M!N!پٵٵj>H*UH* jH*U jUh6CJhjH*UhH*hjH*Uhh>*h0JjU jU j0JUmH >*mH >*@ABCUVCi9: b c ; Y & F( & F $ABCUVCi9: b c ; Y#qNû~vnf^Z t(  Q(  (  6(   (  (  i(  (   ( _`  _         T \]"#qN&'sH8L  & F'h  & F$  & F&  & F#  & F%   & F"   & F! " XW1  & F(&'sH8LDE]^_?"@"y"z"""x%y%,&-&''''';(S(y(|yuqke])   )      MN            -8 9 &   6'  $  T&  #  %  O"  !    $DE]^_?"@"y"z"""x%y%,&-&''''';(S(y((( & F) $? 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Position Statements

From time to time the Society will produce a Position Statement - a statement that presents the Society's opinion about a particular child health issue in the form of a detailed report which explains and/or recommends a particular course of action.  

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