Reframing Primary Health Care for Older Australians

HCCA funds places at key events for our members to attend and participate in policy discussions. The most recent event was the COTA annual policy forum. This is a report from three of our members who attended. 

COTA Australia held their annual national policy forum at the National Press Club on 21 July 2016.

It was an impressive line up of front line policy drivers in the field of primary health care for older Australians, a scenario that gets little traction in the media apart from the supposed impending “tsunami of silver haired” Australians coming to an already overstretched health care sector. Probably the key point to come from the conference was that the numbers didn’t represent an impending catastrophe, but that should be looked at differently, with the societal response to older people needing reframing and older Australians respected because of their contributions to society and their human rights.  

Ian Yates, the CEO of COTA Australia, noted that in a recent survey of their constituents, older people nominated heath as their top issue of concern, a change from the previous top issue of the economy. Health will now be a strategic priority for COTA.

Highlights of the forum were key note presentations from Dr John Beard, Director of the WHO Ageing and the Lifecourse Programme and Prof Diane Gibson, Dean of the Faculty of Health at University of Canberra.

Dr Beard highlighted issues from the recent WHO World Report on Ageing and Health (http://www.who.int/ageing/publications/world-report-2015/en/):

·         Healthy ageing requires an understanding of capacity and environment starting from high capacity where the needs are to help identify and prevent disease onset and adopt appropriate health behaviours; declining capacity where the focus shifts to slow decline often with multiple chronic conditions where prevention becomes important with things like resistance and balance training, and disabled public transport is provided; and finally significant loss of capacity with extensive needs and support;

·         The pressing need is for us to realign the health system to shift from an emphasis on acute care for the individual to care for multiple chronic conditions with better measuring and monitoring;

·         The costs of health care for the ageing need to be seen as an investment in the health system. Better health means long acquired skills and knowledge are maintained with the ensuing benefit to society;

·         Older people need a supportive community NOT always more funding. We need to harness volunteers to work with them within their homes and communities;

·         The term “successful ageing” comes from a US Calvinist perspective and implies there is also ‘failed’ ageing, a better approach would be to emphasis wellbeing “living long, living well”.

Professor Gibson’s research includes the health of older people with delirium and dementia in acute care settings. She began her talk on health care as a human right by detailing a harrowing story of how her mother took 5 days to die in hospital following a fall down a flight of stairs. She detailed other examples of how older people are often stereotyped by the health profession. She gave examples of how the health system treats older people differently and the ignorant assumptions behind them: failing to understand that withholding treatment leads to poorer quality of life, the hostile stereotypes about sexuality and appearance, and the lack of evidence based medicine, for example, with few chemotherapy trials done for the over 70s and rarely including women.

In the panel session on Primary Healthcare – Living Long Living Well, Dr Cathy Mead, President of COTA Victoria, emphasised the need to focus on the broader understanding of primary health care as encompassing the WHO's Declaration of Alma Ata (WHO 1978): “Socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those in most need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes health promotion, illness prevention, care of the sick, advocacy and community development.”  She reiterated that it is crucial to step back from clinical care to a broader public health view and adopt a rights based approach that integrates social and health care. There is inadequate investment in prevention (1.5% of health expenditure) and she asserted that there is even ageism in how this is spent.

Dr Stephen Duckett from the Grattan Institute, gave two presentations, the first about better ways of supporting older people with chronic conditions to self- manage, with a focus on how multiple levels of systems and support can provide care for that individual. He insisted that the person needs to be at the centre of the care system, rather than the GP, and that critical enablers could be supplements to fee for service arrangements such as blended payments. The Grattan Institute publication, The Perils of Place, is also a valuable read about how hospitalisation rates for diabetes, tooth decay and other conditions that should be treatable or manageable out of hospital, show how Australia’s primary healthcare system is consistently failing some communities (https://grattan.edu.au/report/perils-of-place-identifying-hotspots-of-health-inequality/).

Stephen Duckett’s second presentation provocatively asked ‘Can the Health System Afford All These Old People?” And of course the answer was yes! An ageing population is not driving health expenditure and the ‘panic’ about ‘sustainability of the health system is a distraction – we must look at the benefits of health expenditure as well as the costs. The basis of his presentation can be found on The Conversation website: (http://theconversation.com/dont-just-blame-older-australians-for-increased-hospital-demand-62622).

Two other panel discussions covered:

·         Gaps in Access and Affordability in Primary Healthcare, with presentations on Mental Health (Dr Roderick McKay, NSW Institute of Psychiatry), Oral Health (Dr Jane Hartford, University of Adelaide) and Preventative Health (Rosemary Calder, Director of the Australian Health Policy Collaboration).

·         Models of Primary Health Care – What Do Older Australians Need?  The presentation from Dr Steve Hambleton on Outcomes of the Primary Health Care Review and Leanne Wells, Consumers’ Health Forum, on Consumer Focus and Control.

The facilitator Peter Mares summed up the forum with a list of the main points as he heard them:

·              primary healthcare must have the citizen at the centre of circles of care;

·              as we get older we have more teeth than previous generations but more gum disease;

·     better PHC is intrinsically linked better management of chronic conditions, patient engagement and agency and better coordination between systems;

·              more PHC, less hospitalisations;

·             why are we not getting there – increasingly complex systems;

·            Commonwealth/state division of responsibility – states must invest in PHC and preventative health care;

·           misinformation and myths (‘ageism’) about older people seen as a burden and a cost where less value is put on an older life, with no apparent economic importance;

·         BUT we are living longer and are healthier, as a society have plenty of time to adjust and contribute to greater civic leadership and community building.

Sue Andrews, Ros Lawson and Russell McGowan

Launch of Capital Health Network

Yesterday I spoke at the launch of the Capital Health Network. The entity was officially launched by Simon Corbell MLA, Minister for Health and Deputy Chief Minister.

The Chair of the Network, Dr Martin Liedvogal, shared the Blue Print with attendees. This document sets out the roadmap for the Network.

My speech is posted here for people to read. As usual, I strayed from the script a little bit...


Health Care Consumers Association is very pleased to work with the Capital Health Network. We are the peak consumer organisation in the ACT and represent the interests of consumers in our very complicated health system.

Consumers and carers need to have a strong voice not only at the Board level but across the operational areas of the Network. We supported a small group of experienced consumer representatives and advocates to provide important perspectives in the development of the blueprint for the Capital Health Network. We worked closely with the staff to develop the foundation documents.

We need to build our understanding of the needs of the community so that services can be developed and supported to meet those needs. The population health planning function of the Network presents us with an opportunity to refine our health system to keep our community as well as possible.

Primary healthcare is essential to a healthy community. There is a new round of reform being led by the Federal Government and this is driven by the desire to control costs in the health system.  But we need to remember that it should not only be about reducing costs in the short term but how we can improve the health of our communities in the long term. The focus of the reform has to be on spending health dollars on what works the best.

There is also reform in workforce. We are at an interesting point where there are many players stepping into the primary care space. General practice-based primary health care is still key but we are seeing the potential for more services delivered by other health practitioners like health coaches, peer workers in mental health and – dare I say it - pharmacists. And we know that private health insurers in this country are also very interested in how they can offer products to support consumers in primary care.

We are also seeing an increased focus on self care and self-management by people with chronic conditions. Health literacy is the key.

Affordability of healthcare is one of the biggest issues for consumers. Out of pocket costs of primary health care are significant. The MBS rebate has not kept pace with the increasing costs and so many consumers face very real decisions about what services to access or which prescription to fill. Cost to see GPs, medical imaging, pathology, prescription and over the counter medications, physiotherapists, and then there's the cost for dental care.

We need to make primary health care more affordable so people can access the care that will benefit us. The stronger our primary health care the less demand for acute services.

There is much work to do but the Capital Health Network does not have to do this alone. There are roles for the ACT Government, the professional bodies, community services, consumer organisations and of course the Network’s membership.

So in closing I would like to congratulate the staff and Board of the Capital Health Network. I would also like to acknowledge the work of the former CEO Leanne Wells, former Board Chair Rashmi Sharma, and also the role that Vlad Alexandric and Angelene True have played in the transition.

Community based solutions can only be developed in partnership. Clearly the Capital Health Network understands this and we look forward to continuing to work with them to meet the challenges the primary health care system faces and improve the health of our communities.

Darlene Cox
Executive Director

Report on Primary Health Care Research Conference 22-25 July 2014

Report on Primary Health Care Research Conference 22-25 July 2014

By Joanne Baumgartner, HCCA Representative. 

I was lucky enough to be able to attend this conference sponsored by HCCA and I thank the organisation for that as it was a very useful and worthwhile conference to attend. Unlike the previous PrimaryHealth Care Conference that I attended in Brisbane a few years ago, this one was definitely aimed at including the consumer perspective in the majority of sessions that I attended. 

I started off the conference by participating in a Higher Degree Workshop where we were given polo shirts to wear with the words “Agents for Change” written on the back as a catalyst for the day’s workshops. The workshops focused on how we could get our research published and how to write for different purposes and it was a very practical and inclusive day. My reason for being able to participate is that I am currently a Masters student at the University of New South Wales. An added bonus is that I have been given a research profile on the Primary Health Care Research and Information Service, ROAR (Registration of Australian Research) website where my published works are available to read at: www.phcris.org.au/roar/profiles/1751 

Some of the workshops that I attended during the following two days included a very interesting workshop on the use of Tibetan Sound Bowls in a nursing home for people with dementia where people were accommodated in separate houses for 6-8 people and the Sound Bowls were played like musical instruments while everyone sat around a large table , placing their hands on the table so that they could feel the vibrations from the music. The results were that there was a significant drop in the agitation and medication required to subdue people as they were calmed down by the sounds coming from the bowls music. The presenters showed a video of the process of playing the Tibetan Sound Bowls and the subsequent reactions from the people residing in the Aged Care Facility. 

The conference as a whole focused on patient or consumer engagement. A very interesting and particularly enlightening speaker right throughout the conference was Professor Nancy Edwards from the University of Ottawa who presented papers on Implementation research which had the focus of being very practical in that all of her research was developed with specific outcomes as an end result and a requirement of her projects. Her main question to all of us was “How are our research methods driving the questions we ask? ”, and  “What types of interventions do we want ?”. Again I was fortunate enough to be able to attend a follow up workshop with Professor Edwards at the Australian National University as an Alumni of the ANU on the following Monday where we had further discussion on Implementation Research and this knowledge will definitely assist me with my postgraduate studies and further research papers that I may think of writing. 

Since the conference and ANU workshop I have submitted another paper for publication with the Operational Research Society in the United Kingdom of which I am a Member, based on the report that I wrote on Infant Mortality in the Australian Capital Territory 2001-2005 when I was HCCA representative on the Maternal and Perinatal Information Network at The Canberra Hospital.

I hope that this report is useful to health care consumers and again thank you to HCCA for sending me to the conference and I was glad to attend the extra two workshops which were free to me as a postgraduate student.

Joanne Baumgartner

Canberra Home Doctor Service

Many of you may be aware of the new after-hours primary health care service the National Home Doctor Service. 

HCCA met with staff from the Home Doctor Service to find out more about what it can offer in-terms of after-hours care and ask about any issues we could possibly see with their model of care and business model.

The National Home Doctor Service is a pre-existing that has been running for over 40 years in other states and territories with the service running in Canberra since August this year.

The Home Doctor Service provides house calls to people living in the ACT and surrounding areas in the after hours period. 

This is a bulk-billed service for those with a medicare card or those who are part of the Global Assistance Program (for example international students) with no out-of-pocket-cost to the consumer. If you do not have a medicare card there is a flat rate of $200 per hour, but they are looking at working with private health insurers to try to potentially cover people without medicare cards.

This ABC news video released at the start of August explains the billing model and explores the notion that this type of billing may not be the most cost- effective way to spend the health dollar. We asked the Home Doctor Service about this, particularly in relation to whether their call centre referred people to other ACT after-hours services like the Walk-in Centres. Essentially their business model relies on medicare after-hours billing code and they do not refer to other services if they can be seen by the house call doctors, however call centre staff do triage callers and refer them to emergency services if needed.

The Home Doctor Service currently works in both private homes and in residential aged care facilities. They provide electronic health care summaries to peoples regular General Practitioners or GP practices by 8 am the day after receiving the house call. They are also currently set up to upload directly to the Personally Controlled Electronic Health Record, however this is not yet active.

As of September this year the service employed eight local Canberra doctors and two experienced Melbourne locums to help guide the new practice. The number of doctors is likely to have gone up due to the high demand for these services.

HCCA asked the the Home Doctor Service about quality and safety assurance and the use of consumer feedback and was informed that they have an 80% approval rating from feedback provided via e-mail from users. They have Clinical Governance through a Canberra based doctor and are developing a Clinical Governance Committee for the ACT. HCCA has asked that they consider having a consumer representative on this committee.

The Home Doctor Service aims to see people within 3 hours of receiving a call, however due to the huge demand in the ACT the wait may be longer. The Home Doctor Service also informed us that those using the service tended to be sicker than usual presentations in other states and territories. HCCA believes this is demand is likely to be due to the history of under service in primary health care and after-hours services to the ACT community.

Have you used this service? We are always interested to hear about your experiences and to feed this important information to service providers to ensure continuous improvement!

Let us know what you think!

We are open to hearing whether this new service meets the needs of consumers in the ACT and provides better access to after-hours primary care.

Eleanor Kerdo
Policy Officer  



    

International Patient and Family Centred Care Conference #6

Providence Health Care – Shared Care Partners for Patients

Like every other health service Providence are looking at an ageing demographic that is threatening to overload their health care system and this has prompted health care funders to understand that there is a need to have activated, engaged patients. Supporting people to self-manage is certainly one way to deal with the challenge but you can’t have activated and engaged patients who are skilled at self-management unless you have a system that supports consumers and our families in self management.

The Canadian health care system is one of the prized assets of their country, they value this and want to maintain it. This has come up in many of the sessions and as I talk to people about our universal health care and the way in which it is being eroded they understand my anger about this.

The Shared Care Committee initially conceived to improve working relationships between primary and specialty care. Very quickly the made the patients voice an important part of the dialogue. It is a joint project between BC Medical Association and Ministry of Health. At the table is also health authorities, and a patient representative. It has spawned a number of projects wich they listed on their slide, an impressive list that makes me want to find out more. Today they are talking about the project of the lower mainland, around Vancouver.

The challenge to involve patients and look at rational service delivery is most difficult in big cities along the 49^th parallel as they have a model that is costly, disconnected and specialty –centric. Now, the 49^th parallel to me makes my think of a kd lang album and a brewery I found in Vancouver but there is obviously another meaning. 

There are 600 more specialists in Vancouver than family physicians and specialists are not always deployed in the right way, and communication between the two are not always meaningful and patients get lost in the shuffle. So the geography is ripe for improvement in shared care. Sounds a lot like Australian health system.

They want to be able to communicate better, address the access issues that are preventing people from receiving the care they need, to improve patient flow, patient journey. And they want to minimise duplication and inefficiency in the system as it is an issue that is preventing specialists from responding to patient needs. The panel spoke about the benefits of having the Ministry of Health involved and committed to bringing about change. The Ministry also recognises that chronic disease management belongs in the community with the family care provider, not the acute care hospitals. Some hospitals want to get into the business of chronic disease management but this is better placed in the community. So they are very concerned with trying to rebalance the work that is going on between specialities, acute and community based primary care.

The Patient Voices Network in BC is a resource for patient representatives and members of advisory councils. So patients are connected to a broader base. Doctors and those working in the health services are somewhat relieved that the patient representatives do not have an axe to grind.

Patient and provider experience, important to not only engage patients but also health care providers in service redesign. They have three prongs to their work. SLIDE includes cost and one other element I didn't catch but will check out.

They find that it is all too easy to make assumptions about what patients need and what is important to them but to have a patient representative at the table these assumpltions can be unpacked and challenged. For example, the ability to receive a copy of the consultation notes. They want access to this information as they often have the chronic disease for the rest of their life and they want to learn as much as they can about this. But some patients will require more support than others to understand this. And timing of appointments is a big issue as those people who love out of town have difficulty in getting to their early in the morning.

They have guidelines and there is a good slide on this. The first thing they say is: include patients form the beginning and have them as full team members.

They also set out some practical advice about the logistics including providing instruction on how to get to the meeting room, provide refreshments and food and need to check for allergies and sensitivities; provide reimbursement ; think about the time of meetings as many people with chronic conditions have a full time job managing their condition just to get there and some may also need to make arrangements to have time off work.

It was fascinating to hear Robert Levy MD, a respiratory physician, reflect on specialist behaviour. He said that lung, heart, diabetes and kidney team all got together as they realised that they were slow to understand that works for one set of organs may not be helpful to other organs. Their training is very organ specific but their patients have more than one set of organs. I always love hearing this. I know that my body has more than one set of organs. We really need to do something about medical education so that they have a more holistic perspective.

The panel reflected on Successful Initiatives

RACE- RapidAccess to Consultative Expertise. Real time telephone access. It is phone line for family physic and. It is a phone line with a selection of specialty services. In 2010 it started with five services and has grown to 22 services. They take more than 15,000 calls to the line. 78% of calls are answered within 10 minutes and 60% of calls avoid unnecessary consults and 32% of calls avoid unnecessary ED presentations. They have estimated that there is a saving to the system of $200 per call.

They have developed RACE in a box, with 5 page booklet on how to set this up.

RACE calls take about 5 minutes and medication advice, testing advice, affirming the view of the Family Physician. They receive 35% of the usual fee of seeing a patient face to face consult but this will take an hour once they see the patient and then write up the consult. So it does free up resources. 

Acknowledgment of referral – fax back form. This is a great idea as often this is when patients fall into a crevice. I am surprised that the Fax is King. And there was no mention of an electronic solution, shared records.

Notification of admission: So now family physicians are notified that their patients are in hospital. The notification includes an invitation to the FP to participate in the discharge planning process.

Three levels of patient participation: individual, organisations and system

Hang Tough Arthritis Support Group. Arthritis increases your risk of heart disease. And anyone with inflammatory arthritis is at risk, regardless of age and gender. IT is not a benign diseases and we do not need to be protected for the tough messages as we need to know this so we can make decisions around our own care.

Patient Voices Network Framework. Patients as Partners Partnerships Framework looks really interesting. We are currently reviewing the ACT Health Consumer and Carer Participation Framework http://health.act.gov.au/c/health?a=dlpubpoldoc&document=2771so I will definitely be looking at this one more closely.

The slide gives examples of how they contribute. They get a greater understanding of the organisation and the services. They have the positive opportunity to improve the system for others. Many people come to the Network because they experience care that was not a good as it could be and this provides an opportunity t make a difference to others.

A couple of gems from the consumer members of the panel:

We have discovered many of the gaps in the system as we have often fallen through them

What every patient wants is good, safe care in a timely manner

Communication is a theme that emerges across the patient journey: referrals to specials, clarity for patients, consults, support for complex chronic diseases, system acknowledgement of patient realises, hospital communications.

The Patient Voices Network has a series of videos of consumer representatives that you need to watch. Really inspiring!

Another fabulous session that I look forward to sharing with my networks.

Darlene Cox

@darlenecox

Health Pathways for the ACT

On Monday 7 April I attended a joint workshop with ACT Health an ACT Medicare Local on Health Pathways. Eleanor Kerdo and Katrina, a consumer representative with HCCA, also participated.

Leanne Wells (CEO, ACT Medicare Local) formally opened the workshop and provided a brief  introduction of healthpathways, stating that it is an important collaboration between ACT Health and ACTML. Health pathways is a powerful platform to improve services and outcomes for consumers and they see it as an opportunity to develop pathways that put the patient at the centre of care and aspects of the system that need to be improved and enhanced. 

Rosemary O’Donnell (Executive Director Division of Medicine, ACT Health)  reflected on initial introduction to healthpathways as an exciting opportunity. She sees that this is a framework to enhance the patient journey through the system so that it is as seamless as possible. Rosemary commented that there is a large volume of medical services, including people living with chronic disease, and see that there are opportunities for improvement.

Ian Anderson – Streamliners NZ – Canterbury Health System, was the facilitator for the day. 

The idea of HealthPathways grew out of necessity in Christchurch, NZ. Christchurch is similar to Canberra: urban population of 400,000 people, one major tertiary hospital, catchment of 500,000.

In 2006 the Canterbury District Health Board introduced a new approach to working on problems. This involved new language and terminology, and collaborative approach across the system. By 2010 the new approach was starting to reveal results and improvements which resulted in better outcomes for patients. In 2011 Hunter New England asked about their work and they adopted aspects of their ways of working. They have shared their experience with other Australian districts. There are now 12 entities (Medicare Locals and & Local Hospital Networks) in Australia using elements of Health Pathways and six entities in NZ. In total about 10 million patients across Australia and NZ are part of this.

Three main themes:

• The environment and creating fertile ground for collaboration and service improvement
• The detail of service improvement, running work groups and getting change
• The pathways: these are enablers of service change. They reduce variation in the system and improve outcomes

Ultimately this is all about improving services. In order to achieve sustainable change you need all three of these elements. Thee Canterbury story is a classic demonstration of what is possible when managers have a vision and trust clinicians to be involved in bringing about change.

There was a presentation from Carolyn Gullery, the General Manager of Planning and Funding for Canterbury health system, who was one of the prime drivers of change. This was the presentation she made at the ACI in 2013. (20 min video). It is not online but there is a long video (over an hour) online.

Gullery describes the burning platform, with 1 in 5 people over the age of 65, and by 2020 this will grow to be 1 in 3. There is growing demand, with increased admissions to hospital and increased waiting times. If there was not change there would be a need for many more GPs, another tertiary hospital, another 6000 people in the workforce, and another 2000 nursing home beds. Obviously unachievable and not sustainable.

Graphic of Canterbury health system: Connected system, shared vision. One of the elements that appeals to me is that the work was based on a premise that you shouldn’t be in a hospital if you don’t need to be there. A key measure is not to waste people’s time, both patients and clinical staff. At the core of their work is the belief that most people do the right thing if the system enables them.

A collaborative way of working and it was led by clinicians. They had to bring about a big change. They could not wait for incremental change. 

The full story of the transformation as well as the journey they took is available online on the Kings Fund website.

Darlene Cox

Executive Director