Our HealthPathways team has over 250 live pathways accessible via the portal
GP Liaison Units – expanding upon our success
In partnership with the Northern Adelaide Local Health Network, our Northern Adelaide GP Liaison Unit (GPLU) continued for its third year.
Across the year, the team has maintained effective connections with northern practices and engaged even further with hospital consultants, supporting local and state-wide initiatives (Outpatient Department Redesign, Clinical Prioritisation Criteria Working Groups, Secure Messaging Delivery Project). A dedicated GPLU website was developed with information to support GPs in the northern region to better understand how to access referrals and referral management guidelines, including useful contacts for northern based GPs, links to outpatient specialist clinics, and an outline of the specific General Practice Liaison Integration Unit (GPLIU) projects are being undertaken. Projects include GP education sessions, GP referral quality audits and an improvement project targeted towards improving separation summary delivery to GPs.
The Central Adelaide GPLU has had significant success in its second year of operation, despite the impact of COVID-19 reducing the opportunity for the team to physically meet with practices in the central region. Many milestones were achieved in 2021 including the development of a dedicated GPLU website, delivery of numerous webinars providing information about hospital avoidance/substitution programs in the centre, improved discharge summary processes, development of a new e-Referral system to reduce the number of lost referrals and improve real time feedback to GPs, and navigation of the Royal Adelaide Hospital health professionals’ webpage.
The Southern Adelaide GP Integration Unit (GPIU) has also just completed its second year of operation and similarly have had limited opportunities to engage practices in the southern region face to face. A dedicated GPIU website has been developed with region-specific information to support GPs to access urgent and after-hours care; links to outpatient specialist clinics; additional clinical support, SALHN specific information and professional development and networking opportunities.
Supporting providers via peer support networks
This year we commissioned peer support networks, which included the SA Allied Health Professionals Associations Consortium (SA AHP Associations Consortium), Health at Every Size (HAES) Network, PSA Early Career Pharmacist and Dietitian Network and the SA Nutrition Network. These networks have provided opportunities for health professionals to come together from different disciplines and network, share knowledge and support each other.
Through our involvement in the SA AHP Associations Consortium, we supported allied health providers in the COVID-19 response. Representatives from different disciplines came together to discuss common issues affecting their members and develop strategies to support each other and their members. The Consortium served as a platform to communicate a renewed and shared goal of improving patient outcomes by working together as multidisciplinary teams in patient-centred medical neighbourhoods.
The HAES Network brought together dietitians, exercise physiologists and psychologists to discuss and support each other in the practice of weight-neutral, non-diet, client centred, evidence-based approaches to wellbeing. The HAES approach was discussed in application to working with clients in aged care and disability settings, hospitals, and other settings.
The SA Nutrition Network (SANN) brings together nutritionists, dietitians and other health professionals working on nutrition promotion initiatives in population health, community, or health service settings in South Australia. We commissioned the SANN Leadership Group. With our support, SANN developed and hosted a workshop on lived experience in nutrition practice, policy, and research.
The PSA Early Career Pharmacist and Dietitian Network brings together pharmacists and dietitians who are early in their career. They have hosted networking and education sessions on mental health and aged care, providing an opportunity for shared understanding of the role of each discipline and how the two disciplines can work together to improve patient outcomes.
Priority Care Centres - providing alternative pathways of care
Our 4 Priority Care Centres continue to offer urgent care services across metropolitan Adelaide, reducing the impact of triage 4 and 5 patients presenting to Emergency Departments.
Referral pathways to care continue via the South Australian Ambulance Service (SAAS), local hospital Emergency Departments, internal GP or other practice, state funded community health settings/services, and SAPOL.
Over the year, 8,221 patients have been seen across our 4 sites.
HealthPathways SA – collectively working together to improve pathways of care
Working in partnership, Wellbeing SA, Adelaide PHN and Country SA PHN are jointly responsible for implementing HealthPathways across South Australia to support consistent care and management of health conditions and to improve the health outcomes and journey of patients through our local health system.
This year, the project has seen a strong integration focus in collaboration with our GP Liaison Officers, Adelaide PHN, the broader mental health sector, palliative care, and older persons sector (across both metropolitan Adelaide and Country South Australia). The project brought these stakeholders together to collaborate on improving peoples’ experiences and journeys through the local health system.
Over the year, HealthPathways SA onboarded and trained 2 additional clinical coordinators, enhancing the program’s ability to deliver on key objectives and improve care. HealthPathways SA has also been embedded into the Outpatient Redesign, which is a whole of state project aiming to deliver an appropriate, timely and efficient outpatient service.
The project achieved significant milestones across 2020/21, including the:
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Development of 12 Diabetes and Endocrinology Pathways, representing a fifth of new pathways and providing support for clinicians to deal with the burden of this disease
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Development of 8 Paediatric Pathways, providing concise guidance for conditions managed in primary care that could potentially reduce the pressure on hospital emergency departments
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Formal review of 69 clinical, resource and referral pages, with a further 39 pages scheduled for review over the coming year
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Development of over 40 pathways relating to complex/multifaceted conditions and commonly referred conditions
A further 86 new pathways are in development including 4 Youth Mental Health Pathways, a key activity underpinned by the Towards Wellness Plan. This year’s development activities included running 4 clinical workgroups with 42 participants. The aim of the workgroups was to identify issues, gaps and to clarify starting points for the detailing of current services available to this population. Each workgroup contained a mix of clinicians and participants from the primary, tertiary, and acute sectors with expert, local clinical knowledge on services available for young people aged 12 to 25 years.
Rich discussion and data from the workgroups set in motion enhanced stakeholder engagement, sector buy-in and guided the adaption of 4 clinical pathways. The pathways outline unique assessment and management tools and defines local child and youth mental health referral criteria. The four Youth Mental health pathways are on track to be launched in September 2021.
This year, HealthPathways SA also developed eagerly awaited pathways such as benzodiazepine withdrawal, psychosis in adults and deliberate self-harm, adding to the 39 Adult Mental Health and Addiction Medicine Pathways developed since 2018. The pathways added this year were written by our GP editors with input from over 35 GPs, hospital-based specialists, nurses, allied health professionals and other subject matter experts.
Health Care Homes - helping people to better manage their conditions by providing access to coordinated, integrated, and tailored care
Background
Adelaide PHN was one of the ten regions selected for the stage one roll-out of Health Care Homes (HCH).
HCH is a Commonwealth funded initiative, designed to improve care for the growing number of Australians living with long-term chronic conditions. The HCH model was designed to help people better understand their conditions by providing access to coordinated and integrated care, tailored to their needs.
Program wrap-up
The program originated from the recognition that one in four Australians have at least two chronic health conditions and require care from a range of health care professionals. HCH was introduced to improve coordination of care between the different health care professionals in a patient’s care team, resulting in reduced costs, improved patient safety and satisfaction.
Involved practices enrolled patients into the HCH program and rated their risk with the CSIRO Risk Stratification Tool. A new bundled payment system was trialed, allowing practices to step away from the Medicare fee for service model for their enrolled patients’ chronic conditions, and to trial new and innovative ways for management. The bundle payment enabled easier access to health care, with different consulting methods being trailed. Some practices used the bundle payment to fund group exercise classes, as well as falls and balance classes for healthy ageing. Group classes provided opportunities for peer support, more efficient health activities (reaching a greater section of the population) and social connectedness. It also provided funding opportunities for consults with exercise physiologists, physiotherapists, and other allied health providers beyond the visits funded by Medicare under a Team Care Arrangement.
In June 2021, there were 7,810 patients enrolled in 106 HCH practices around Australia, with 13 HCH practices and 1,732 patients in Adelaide.
The HCH practices and their patients found the program to be a great success and saw overall improvement to health care. The practices could trial telehealth consults prior to its introduction to Medicare during COVID-19. Telehealth enabled patients to access care remotely when they couldn’t attend face to face consults due to work/carer responsibilities, mobility/transport access issues and other reasons. Telehealth helped patients to remain up to date with their care and provided more efficient and convenient access to scripts and repeat referrals (with appropriate discretion).
HCH saw the introduction of funded nurse-only consults, where nurses could educate, counsel, and motivate patients. This extra support has seen patients come off pain medications, feel more confident, lose weight effectively and safely, and has contributed to fewer hospital admissions and Emergency Department presentations.
Some HCH practices trialed the Ward Round concept. Nurses and/or medical practice assistants met with doctors and followed up with patients, organising pathology forms and measures to be performed for a patient prior to their appointment. This helped to prevent patients 'slipping through the cracks' and increased care efficiency overall.
The HCH practices utilised Inca, an electronic shared care planning portal. Inca meant that up-to-date patient health information was easily accessible to all members of a patient’s care team (including their doctor and nurse team, allied health, specialists and for some practices the hospital). Patients could use Inca to access their own notes, documents, summaries and referrals, as active members of their care team. Inca was also implemented into two Northern Adelaide Local Health Network (NALHN) Hospitals, a big step in the journey towards efficient and timely information sharing between primary and tertiary health care.
HCH practices reported that the HCH funded focus on the quadruple aim and clinician experience helped them to discuss burnout and burnout prevention more frequently, and to identify opportunities to enhance workplace wellness. Strategies included avoiding work on days off (scheduling work appropriately), ongoing peer support, healthy physical and psychological habits within clinics. This facilitated modelling of healthy habits for trainees and newer members of teams and building healthier practice cultures.
Overall, the HCH program was a big success for the involved practices, improving patient health outcomes. It demonstrated how a Patient Centred Medical Home model and coordinated patient care could work towards achieving the quadruple aim of primary health care.
Patient outcomes
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A supported client in a residential aged care facility lost over 40kg whilst enrolled in the HCH program. Significant education, counselling and encouragement contributed to this result which would not have been possible without the HCH program.
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An anxious patient who visited the GP regularly and could not think of anything other than their next appointment and whether they would still be here, gained confidence through the HCH program. Now post HCH, this patient has moved state, is loving life, has a new GP, and is very settled in Tasmania.
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Pre-HCH, a patient with bladder/bowel fistula’s post radiotherapy was in and out of hospital and on lots of medication and painkillers, which were not working. Through HCH, extra time was spent with the patient and with lots of education and encouragement by their pharmacist, different avenues were explored. The patient is now happily off all medication, pain free, and feels fitter than they have for years. They want to know when HCH will be back as it is ‘the best thing since sliced bread!’.
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Another patient who was very stressed with financial difficulties, housing issues and a lack of support had unstable diabetes. HCH allowed the practice to provide letters of support regarding the patient’s mental health and housing situation. They have now moved to subsidised rental accommodation in ECH, overlooking the ocean and has stabilised diabetes. They ‘pinch themselves’ every morning they wake up, looks out at the ocean, and knows they don’t need to work anymore.