Embed Size (px)
Citation preview
Renal Stakeholders Forum:Outcomes
Renal Health Network Third Stakeholders Forum 12 May 2011
2
Table of Contents 1. Introduction ............................................................................................................. 3 2. Forum aim................................................................................................................ 3 3. Objectives................................................................................................................ 3 4. Attendance .............................................................................................................. 4 5. Format...................................................................................................................... 4
5.1 Presentations .............................................................................................................4 5.1.1 Keynote Speaker ..........................................................................................4 5.1.2 Dr Felicity Jefferies .......................................................................................5 5.1.3 Dr Anil Tandon..............................................................................................5 5.1.4 Dr Ashley Irish ..............................................................................................5
6. Workshop sessions ................................................................................................ 6 7. Outcomes and actions ........................................................................................... 7
7.1 Workforce...................................................................................................................7 7.2 Palliative Care............................................................................................................8 7.3 Primary care interface, targeted early screening and early intervention ....................9 7.4 Information and education .......................................................................................10
8. Forum closure ....................................................................................................... 11 Appendices .................................................................................................................. 12
Appendix 1 Forum programme ...................................................................................12
Appendix 2 Five domains within the CKD Model of Care recommendations .........13
Appendix 3 Results priority recommendations polling ............................................14
Appendix 4 Feedback workshop sessions ................................................................15
Appendix 5 Evaluation report renal forum May 2011 ................................................26
3
1. Introduction
The previous Renal Stakeholders Forum held in May 2008 determined that the top three key recommendations from the Chronic Kidney Disease (CKD) Model of Care (MOC) to be implemented by the Area Health Services (AHSs) were: Recommendation 2: that a targeted opportunistic screening program in primary care among high-risk individuals to identify those with CKD is promoted and appropriate treatment be provided in those patients identified with early CKD. Recommendation 3: that community services and chronic disease management teams be utilised to facilitate the development of clients self-management skills and to case manage patients with multiple and complex co-morbid conditions. Recommendations 14-16: that appropriate staffing and service levels be funded to ensure optimal renal services in the appropriate location, that the number of nephrologists meets national and international workforce standards and that the dialysis care assistant role be established in order to overcome the critical shortage of nurses. Below is the link to the CKD Model of Care: http://www.healthnetworks.health.wa.gov.au/projects/kidney_disease.cfm
2. Forum aim
The Renal Health Network (RHN) Executive Advisory Group (EAG) convened a Renal Stakeholders Forum on 12 May 2011 in order to review the implementation of the CKD MoC priority recommendations within the AHS. The forum was designed to determine what further actions are needed and how priority recommendations could be implemented by the members of the Renal Health Network.
3. Objectives
1. To increase awareness of:
i. Western Australia (WA) Health reforms and impact on renal care
ii. WA Country Health Service (WACHS) Dialysis Plan for the next 10 years
iii. Palliative care relating to end stage renal failure and Advanced Health Directives.
2. To share information on the progress of the CKD MoC implementation. 3. To provide opportunity for participants to share successes and challenges of the MoC
implementation. 4. To identify which CKD MoC recommendations are priorities for action and whether
these priorities differ from those identified in the 2008 forum. 5. To develop an Action Plan to implement these recommendations. 6. To form workgroups and forge partnerships to facilitate implementation.
4
4. Attendance
There were seventy six participants comprising of consumers and carers (6.5%), health professionals (50%), medical practitioners (10.5%), renal physicians (12%), researchers (2%), administrators (12%) and planners (6.5%). They represented government and non-government organisations and the private sector.
5. Format
1. Presentations
2. Two workshop sessions
See Renal Stakeholders Forum program – Appendix 1
5.1 Presentations RHN Clinical Lead Dr Harry Moody opened the forum with welcome to the country. He reminded the forum that the RHN includes everyone involved in kidney health whether government, non-government or private sector and placing consumers and carers at the central focus. Hence, everyone has a role to play in implementing the CKD MoC to improve renal care.
Dr Moody provided a brief overview of the CKD MoC recommendations. He set the scene for the afternoon activities informing the participants that they were there to network, to share information and to develop an action plan to implement the CKD MoC recommendations by nominating the top two or three priorities determined by discussion during the second workshop session.
5.1.1 Keynote Speaker
Mr Kim Snowball, Director General of Health gave an overview the WA health reforms and their impact on renal services.
Key messages: growing service demand and consumer expectations with workforce shortages and
ageing population changing demography and illness patterns growing cost of services and the need to ensure safety and quality from 1990 to 2005 end stage kidney disease (ESKD) in WA grew by 139% with 281%
growth of dialysis activities CKD MoC, evidence-based framework for long-term planning focus on prevention and early detection programs and reducing the burden of
hypertension and diabetes, the most common causes of ESKD increasing treatment access for Aboriginal people – WACHS Dialysis Plan 2011 to 2021 $57m new federal funding for renal services expansion across regional WA E-health reforms improving patient outcomes via better management of patient history
across integrated systems – WA Nephrology Database (WAND) ABF/ABM Activity Based Funding and Activity Based Management placing renal patients
as the focus of activities and services.
5
5.1.2 Dr Felicity Jefferies
The second speaker Dr Felicity Jefferies, WACHS Exec Director Medical Clinical Services Reforms spoke on the implementation of the WACHS Dialysis Plan 2010-2021. Below is the link to the Plan.
http://wachs.hdwa.health.wa.gov.au/index.php?id=7263
Key messages meeting 95% of dialysis demand in regional WA with 5% anticipated to require high acuity
tertiary care providing care closer to home with innovative hub and spoke delivery model utilising primary and secondary CKD management and comprehensive database and
shared clients record across the regions flexible workforce model of multi-disciplinary renal regional teams with renal GPs, nurse
practitioners and renal Aboriginal Health Workers working with visiting renal residents and nephrologists
implementing new models for regional and remote locations Expanding dialysis services in Derby, Kununurra, Fitzroy Crossing, Roebourne,
Laverton/Leonora, Kalgoorlie and Bunbury.
5.1.3 Dr Anil Tandon
The third speaker Dr Anil Tandon, Clinical Lead Palliative Care Network topic was on palliative care and Advanced Health Directives in end stage renal failure.
Key messages patients who start dialysis over the age of 65 years have a 5 year median survival of 15% for older patients with comorbidities, dialysis may not offer any survival advantage there is a high symptom burden similar to cancer patients whether or not they receive
dialysis futility of care is underpinned by medical, psychological, ethical, legal concerns if
treatment is withdrawn or with-hold Advanced Health Directives (AHD) are underused due to self denial in future serious
illness and death, belief in medical advances and technology to stay alive de-medicalise dying and improve AHD awareness through information and engagement
without using AHD as a basis for the futility of care or the high cost of care end-of-life discussions and more palliative care rather than aggressive medical
interventions have shown cascading benefits with no evidence of increased emotional distress or psychiatric morbidity
better quality of death process and for surviving caregivers, less regret, improved physical and emotional health.
5.1.4 Dr Ashley Irish
Clinical Lead Dr Ashley Irish explained the link between the CKD MoC, the Clinical Services Framework and the Activity Based Funding and Management (ABF/ABM). Activity is funded on outcomes based on quality and safety and not historical inputs.
6
Dr Irish also reported on the CKD MoC implementation progress and initiatives on the recommendation priorities identified at the 2007 and 2008 forums carried out within the AHSs.
Achievements: Developed a CKD MoC and an early CKD screen and referral algorithm. Developed the WA Renal Dialysis Plan 2008-2013. Re-established the Renal Dialysis Reference Group. Facilitated the WA Nephrology Database (WAND) on-going development by Health
Information Network for state-wide roll out. Reviewed state-wide home therapy services in order to improve uptake and delivery
(draft report completed). Reviewed haemodialysis vascular access (VA) in WA and evaluated the specific needs of
the ATSI people and delivery pathways (report to be finalised).
Other Initiatives by AHSs: Establishing a CKD clinic at SCGH. Forming the WA Renal Education Services (WARES) by renal nurse educators from the
three tertiary hospitals in partnership with Kidney Health Australia (KHA), Fresenius and renal dietitians to provide information and education to renal patients.
Forming the WA Renal Access Services by the renal access nurses from the three tertiary hospitals.
Conducting annual free screening for CKD during Kidney Health Week by Armadale Health Service in partnership with KHA.
Conducting the Armadale Bentley chronic disease project to publicise support services in the community and developing a directory to facilitate discharge referral options.
Promoting early CKD detection and appropriate timely specialist referral through the GP renal education sessions conducted by the WA nephrologists and supported by KHA.
6. Workshop sessions
There were two workshop sessions.
The CKD MoC recommendations were categorised into five domains: (Appendix 2)
Domain 1: Primary care interface, screening, referral and self management (recommendations 2, 3 and 4)
Domain 2: Information & Education (recommendations 5 and 6)
Domain 3: Best practice CKD management (recommendations 7 to 9 and 10 to 12)
Domain 4: Palliative Care (recommendation 13)
Domain 5: Workforce (recommendations 14 to 16)
The themes of the workshop centred on the following questions:
1. What has been done? 2. What needs to happen? 3. What can I do? 4. What can my organisation do?
7
Workshop 1: Reviewing and sharing information.
A facilitator with seven to nine participants were allocated to a table
Participants moved to different tables to complete all 5 domains
Workshop session 2: Action setting.
Participants returned to their original allocated table.
At the start of this session participants voted for the top three recommendations they considered as priorities requiring action.
The workshop activities focused on:
1. what needed to be done?
2. how could this be achieved?
3. with whom and when?
At the end of the session each table presented an action statement on “what we are going to do and what are the KPIs.”
7. Outcomes and actions
Similar to prior workshops, workforce issues was again voted as a top priority. Palliative care was the second priority and this was closely followed by early targeted screening and early intervention, best practice CKD management and information and education respectively.
Apart from palliative care, the priorities identified at this forum were similar to the ones identified at the 2008 forum as described in the introduction section. These results indicate the importance of continuing the initiatives and further implementation of these recommendations.
Polling results - Appendix 3
Clinical Lead Dr Ashley Irish observed that whilst workforce is integral to all service delivery these issues are high level system wide issues that individuals on the coal face have limited capacity and influence to rectify or implement. For example increasing the number of trainee nephrologists, renal nurses or other clinicians was beyond the scope of this group. Dr Irish suggested that participants from the different tables with a great interest in workforce group together to develop strategies to address the workforce renal shortage. He encouraged the other participants to work on the other top three recommendations voted as priorities.
The full verbatim feedback from the workshop sessions are provided in Appendix 4. The key points from the overall discussion are listed below.
As indicated in the attached feedback, not all the question of how, with whom and when, were answered.
7.1 Workforce Recs 14-16: that appropriate staffing (nurses, allied health) and service levels be funded to ensure optimal renal services in the appropriate location, that the number of
8
nephrologists meets national and international workforce standards and that the dialysis care assistant role be established in order to overcome the critical shortage of nurses.
It is recognised that WA has a renal workforce shortage of renal physicians, nurses and allied health. Renal workforce shortage is especially critical in the rural and remote communities. These communities have difficulties in attracting and retaining health staff.
What needs to happen? Training renal GPs; initiating rural clinical placements for registrars and using a buddy
system for local doctors. Integrating price-per-treatment (PPT) for dialysis with the number of renal physicians
required. Standardising contracts to include Aboriginal Health Workers and medical FTE to patient
ratio. Training more Aboriginal Health Workers and dialysis care assistants. Training renal enrolled nurses. Using renal support nurses in GP practice. Using telehealth and telemedicine more extensively. Employing nurse practitioners especially in rural areas with non existent renal physicians. Ensuring continuous professional development and skills maintenance for rural renal staff Swapping staff between rural and metropolitan locations and rotation of satellite unit
nurses and tertiary centres to maintain skills. Key performance indicators (KPIs) decreased number of referrals to tertiary centres from rural regions reduced waitlist numbers in tertiary centres reduced late referrals timely referral for haemodialysis vascular access.
Action: requires support from Chief Executives and high level decision makers to implement the recommended strategies above as workforce is system wide health planning issues.
7.2 Palliative Care Rec 13: that the Palliative Care Network works with existing organisations for conditions other than cancer to develop an appropriate model of care to meet the needs of people with non-malignant disease.
What needs to happen? education and training in palliative care for nurses, social workers and medical staff inclusion of palliative care in nursing and medical curriculum renal registrar placement in palliative care unit as part of training raise awareness of Advanced Health Care Directives and encourage discussion with
patients and carers clear palliative referral pathways use and modify New South Wales St Georges palliative care model use multi-disciplinary approach early introduction of topic to patients and carers with information and education
9
support from key leadership care plan to include palliative care and ongoing support Liverpool care pathway for end of life care.
Action
RHN to facilitate formation of a renal palliative care workgroup from already identified members by July 2011:
Engage with Palliative care team from Palliative Care Health Network. Engage with St. George NSW and adopt its palliative care model modified to suit WA
needs. Develop an implementation plan and adjust for WA. Work with Area Health Services and WA Country Health Services (WACHS). Engage with consumers and family. Partner with non profit organisations. Implement a pilot program prior to staged state wide implementation of model, led by the
tertiary institutions. Modify program for rural sector.
KPIs timely withdrawals satisfaction survey of carers and relatives % with Advanced Health Care Directives (AHCD)/ Not For Resuscitation (NFR) etc % not commencing on dialysis or on dialysis for a short time reduced hospitalisation rates.
7.3 Primary care interface, targeted early screening and early intervention Rec 2: that a targeted opportunistic screening program in primary care among high-risk individuals to identify those with CKD be promoted and appropriate treatment be provided in those patients identified with early CKD.
What needs to happen: Raise awareness through education at school. Raise awareness of risk factors through mass media. Provide culturally appropriate education and resources such as those provided by the
Kimberley Aboriginal Renal Services. Promote targeted screening based on high risk factors with feedback and follow-up. Offer targeted screening at pharmacies, work places, shopping centres, rodeos, Royal
Show. Team up with other groups such as Diabetes Australia, Heart Foundation. Develop linkage with industry such as mining companies. Train practice nurses to do screening at GPs surgery.
10
KPIs increased early detection decreased late presentation
Action: continue collaboration amongst primary and community care sectors with engagement and involvement of industries, agencies and organisations to promote prevention and early targeted screening of high risk factors for CKD. Comment: It is also valuable for RHN to partner and collaborate with the newly established Department of Health Chronic Disease Prevention Directorate initiatives on health promotion and disease prevention programs.
7.4 Information and education Rec 5: that all CKD patients have access to information that enables informed decisions, encourages partnership in decision-making and an agreed care plan to support disease management to achieve the best possible quality of life.
A plethora of information is available to the community offered by Kidney Health Australia, Baxter renalinfo website and others, NSW Health Renal Resource Centre, booklets and DVDs. However, some of the information may not be accessible to the target group or they are unsuitable and not culturally appropriate. The Kimberley Aboriginal Medical Council has developed culturally sensitive educational materials. What needs to happen?
Provide accredited training with culturally appropriate component for renal nurse educators with full time career pathways.
Promote self education modules (for general understanding). Employ more Aboriginal Health Workers. Employ dedicated Aboriginal Health Liaison Officer (AHLO) at RPH. Forge partnership with Aboriginal Medical Services in rural remote areas as AHLOs are
non-existent. Train Aboriginal Health Workers to be educators. Forge partnership with pharmacies to develop standard endorsed renal medication
information. Develop and promote interactive educator led learning for renal patients. Train patients early using hands on experience or watching others. Make information more available to the community by distributing them more widely. Use a central point to promote and publicise education events. Train nurse practitioners to run mobile clinics in the rural and remote areas to screen high
risk patients and co-ordinate mass screening. Establish CKD multidisciplinary clinics to manage stages 3 to 5 kidney patients.
Action: RHN to facilitate the establishment of a workgroup to develop a multidisciplinary CKD clinics model in the community to manage patients with established kidney disease to minimise disease progression and to refer to nephrologists for timely vascular access procedures. Comment: The proposed target date for submission of the model to SHEF for endorsement is June 2012.
11
KPIs
numbers of patients seen biochemistry markers eGFR (estimated glomerular filtration rate) referred healthy markers e.g. BMI (body mass index) and BP (blood pressure) number of patients progressing to dialysis Quality Of Life indicators.
8. Forum closure
In summarising the feedback from the tables on workforce issues and the other top priorities described above, Dr Irish commented that the recommendations considered as priorities in the 2008 forum remained the current priorities in 2011. Implementation of these priorities such as targeted screening, early intervention, information and education is an on-going process. Workforce issues will also remain priorities in the long term.
Dr Irish recommended that participants registered their interest on the work group form provided in their folder. They will be contacted to form workgroups to progress implementation of the priorities identified such as palliative care.
Dr Moody thanked the participants for their contribution and reminded them to complete the evaluation form and to provide feedback on the WA Primary Health Care - consultation document.
The forum closed at 5.10pm.
The evaluation report is in Appendix 5
Appendices
Appendix 1 Forum programme
Third Stakeholders Forum Renal Health Network Thursday, 12 May 2011 Time 12:00pm – 5:00pm Polly Farmer Room, Gate 6, Paterson Stadium (Formerly Subiaco Oval) Subiaco
12:00 – 12:30pm Registration and lunch on arrival
12:40 Welcome to country, setting the scene for the Forum Dr Harry Moody Renal Clinical Lead
Presentations
12:50 WA Health Reforms Mr Kim Snowball Director General of Health
1:10 WACHS Dialysis Plan 2010 – 2021 — Implementation of services aligned with CKD Model of Care
Dr Felicity Jefferies WACHS Exec Director Medical Clinical Services Reform
1:30 Palliative Care and Advanced Health Directives in relation to CKD Model of Care
Dr Anil Tandon Clinical Lead Palliative Care
1:50 Progress and outcomes of the CKD Model of Care implementation in the Metropolitan Area Health Services
Dr Ashley Irish Renal Clinical Lead
Workshop 1
2:05 Review and share information on the CKD Model of Care implementation
All tables
3:10 – 3:30pm – Afternoon Tea
Workshop 2
3:30 Action setting: what needs to be done, how, with whom and when
All tables
4:20 Reporting Action statements: What we are going to do. Table Reporters
4:50 Summary and call to action Dr Ashley Irish
5:00 pm thank you and close forum – Dr Harry Moody
Appendix 2 Five domains within the CKD Model of Care recommendations
Domain 1: Primary care interface, screening, referral and self management Rec 2: that a targeted opportunistic screening program in primary care among high-risk individuals to identify those with CKD be promoted and appropriate treatment be provided in those patients identified with early CKD.
Rec 3: that community services and chronic disease management teams be utilised to facilitate the development of clients self-management skills and to case manage patients with multiple and complex co-morbid conditions
Rec 4: that the guidelines “Referral to Nephrology Specialist Outpatient Appointment” across the state and the intake and timeliness of referral be monitored
Domain 2 – Information & Education Rec 5: that all CKD patients have access to information that enables informed decisions, encourages partnership in decision-making and an agreed care plan to support disease management to achieve the best possible quality of life Rec 6: that all units responsible for preparing patients for dialysis have adequate number of experienced and trained Nurse Educators supported by Aboriginal Liaison Officers appropriate to the number of Aboriginal patients under care
Domain 3 – Best practice early management Recs 7-9: that dialysis access surgery meets the international benchmarks with adequate surgeon and nurse specialist support and that a dedicated central line insertion service via radiology be established to maintain best practice outcomes for CKD patients
Recs 10-12: that integrated and multi-disciplinary CKD management clinics for all patients with advanced stage CKD be established in metropolitan centres and selected rural and remote regions
Domain 4 – Palliative Care Rec 13: that the Palliative Care Network works with existing organisations for conditions other than cancer to develop an appropriate model of care to meet the needs of people with non-malignant disease
Domain 5 – Workforce Recs 14-16: that appropriate staffing (nurses, allied health) and service levels be funded to ensure optimal renal services in the appropriate location, that the number of nephrologists meets national and international workforce standards and that the dialysis care assistant role be established in order to overcome the critical shortage of nurses
Appendix 3 Results priority recommendations polling Renal Forum - Workshop 2: Action setting Recommendations
Tabl
e 1
Tabl
e 2
Tabl
e 3
Tabl
e 4
Tabl
e 5
Tabl
e 6
Tabl
e 7
Tabl
e 8
TOTA
L
Recs 14-16: that appropriate staffing (nurses, allied health) and service levels be funded to ensure optimal renal services in the appropriate location, that the number of nephrologists meets national and international workforce standards and that the dialysis care assistant role be established in order to overcome the critical shortage of nurses
10 1 8 14 2 5 6 7 53
Rec 13: that the Palliative Care Network works with existing organisations for conditions other than cancer to develop an appropriate model of care to meet the needs of people with non-malignant disease
1 2 7 1 13 6 8 11 49
Rec 2: that a targeted opportunistic screening program in primary care among high-risk individuals to identify those with CKD be promoted and appropriate treatment be provided in those patients identified with early CKD.
5 9 5 5 9 10 3 1 47
Rec 5: that all CKD patients have access to information that enables informed decisions, encourages partnership in decision-making and an agreed care plan to support disease management to achieve the best possible quality of life
5 3 5 12 3 12 4 2 46
Recs 10-12: that integrated and multi-disciplinary CKD management clinics for all patients with advanced stage CKD be established in metropolitan centres and selected rural and remote regions
7 5 5 4 0 6 3 7 37
Rec 6: that all units responsible for preparing patients for dialysis have adequate number of experienced and trained Nurse Educators supported by Aboriginal Liaison Officers appropriate to the number of Aboriginal patients under care
2 2 9 3 5 3 3 3 30
Rec 3: that community services and chronic disease management teams be utilised to facilitate the development of clients self-management skills and to case manage patients with multiple and complex co-morbid conditions
3 2 3 3 0 2 9 0 22
Recs 7-9: that dialysis access surgery meets the international benchmarks with adequate surgeon and nurse specialist support and that a dedicated central line insertion service via radiology be established to maintain best practice outcomes for CKD patients
0 0 0 0 3 0 0 7 10
Rec 4: that the guidelines “Referral to Nephrology Specialist Outpatient Appointment” across the state and the intake and timeliness of referral be monitored
2 0 0 0 2 2 0 0 6
Appendix 4 Feedback workshop sessions The information listed below is the verbatim feedback from the workshop sessions.
Domain 1: Primary care interface, screening, referral and self management
What has been done:
1. Aboriginal Health Service - AHS: currently following - up on 500 people (weight, height, BP, blood glucose level, cholesterol etc) tracked on MMeX
2. Primary Care has Guidelines side bar red book screening seen every year, dip test College GPs Medicare
3. Kidney Health Australia - Renal Health Check child health adult checks free annual screening during Kidney Health Week
What needs to happen
still late referral of Stage II or III – importance of awareness and risk factors education such as high blood pressure and diabetes
raise awareness through education at school to mass media provide culture sensitive education and resources such as those provided by the
Kimberley Aboriginal Renal Services promote targeted screening based on high risk factors with feedback and follow-up screen at pharmacies, work places, shopping centres, rodeos, Royal Show team up with other groups such as Diabetes Australia, Heart Foundation develop linkage with industry such as mining companies screen by practice nurses in GPs surgery home checks
KPIs
1. increased early detection 2. decreased late presentation
Domain 2: Information and education
What has been done
1. a plethora of information is available in the community (brochures, DVDs, booklets) and on the internet:
2. Baxter: www.renalinfo.com
3. Kidney Health Australia (KHA): Kidney Health Information Service (KHIS) line 1800 – comprehensive kidney health and disease information line for staff and patients Australia wide
4. NSW Health: Renal Resource Centre – provides information, education and resources 5. multimedia – infomercial, booklets, posters in medical centres 6. nutrition: Nutrition education on line (NEMO) which is Queensland based 7. Dietician Association of Australia Renal Interest Group (DAARIG) WA Branch –
dieticians belong to this group
South West
patient Seminar twice a year in Bunbury dialysis nurses doing patient education. patient support group in Bunbury/ Busselton run by patients meets bi-monthly. The
group provides information on treatment options and other relevant information
Albany
telehealth ESKD session with nurse sitting in education session by the WA Renal Education Services covering early kidney disease
to end stage.
Fremantle
CKD nurse x 1 dedicated to patient education (0.4 Full Time Equivalent). WA Renal Education Services (WARES), a collaborative initiative of the three tertiary
hospitals, KHA and Fresenius provide education on end stage kidney failure delivered three times a year in the metropolitan area.
Aboriginal Health Workers x 2 in Rockingham
Kimberley
designated 2 FTE to educate staff and CKD patients - early stages 1, 2, 3 screening days with data collected - Aboriginal Health Worker work with CKD patients but not on renal patient follow-up
pre dialysis education for stages 4 to 5 Kimberley has developed its own culturally appropriate resources collates a vascular access list for timely referral.
What needs to happen?
Provide accredited training with culturally appropriate component for renal nurse educators with full time career pathways.
Promote self education modules (for general understanding). Employ more Aboriginal Health Workers (“Raelene” at SCGH) +3. Employ dedicated Aboriginal Health Liaison Officer (ALO) at RPH. Forge partnership with Aboriginal Medical Services in rural remote areas as AHLOs are
non-existent. Train Aboriginal Health Workers to be educators. Form pharmacy network to provide standard endorsed renal medication information Develop and promote interactive educator led learning for renal patients
Train patients early using hands on experience or watching others Make information more available to the community by distributing them more widely Use a central point to promote and publicise education events Train nurse practitioners to run mobile clinics in the rural and remote areas to screen
high risk patients and co-ordinate mass screening. Establish CKD multidisciplinary clinics to manage stages 3 to 5 kidney patients
CKD clinic model
Referral Resources Staffing E-health Where? From: GP Nurses Aboriginal
Health Workers
Nephrologists To: CKD Clinic Nurse
Practitioner led clinics
Allied Health Quality Of Life
Clinic
Advanced Care Plan (ACP) CKD Pathway Prof. ACP Develop. ACP Train the
trainer education (staff)
Seminars
- GP - Nephrologists - Nurse
Practitioners - Educators - Aboriginal
Health Workers
- Dietician - Pharmacist - Social Workers“Palliative Care” NO type 2 staff - Podiatrists - Dialysis
educator
- WA Nephrology Database
- Tele-health - Access to all
WA - Flagging of
EGFR to CKD clinic
- WA Information
- Everywhere - Tertiary - Community - Rural - Remote
HOW Healthy Kidney
Education
Nurse Practitioner led clinics – educator
Clinics attached to pharmacists
KPI Numbers of
patients seen Biochemistry
markers EGFR referred Healthy
markers e.g. BMI/BP
Number of patients progressing to Dialysis
Quality Of Life tools
Multidisciplinary CKD Clinic / Education
What How Who When
Primary Health Care checks
Groups of Chronic Disease Specialist
Diet Pharmacist
Now
Domain 3: Best practice CKD management
What has been done?
Renal Health Access Group – Project officer completed an audit in 2009 FH and SCGH have a similar approach to vascular access line insertion that
incorporates Radiology expertise. These 2 services have regular meetings with a multidisciplinary teams and a standardised approach to line insertions.
SCGH has a multidisciplinary CKD clinic that sees referrals from nephrologists of pre dialysis patients that provides education to patients and medical management with the aim of delaying the time to dialysis and providing greater information around the expectations to dialysis.
All tertiary hospitals now have a vascular access nurses Line insertion – an audit with RPH has taken place to identify best practice around the
selection of resources for vascular access. Outreach program in the Kimberley whereby at least 4 patients have vascular access
procedure performed by the visiting surgeon. St Vincent’s in NSW commenced a CKD clinic and Palliative care clinic working in
parallel assisting patients to have a seamless journey through management of their condition when approaching the palliative care stage of their disease. The model is to be evaluated and would be valuable to pilot in WA.
WA renal nurses meet regularly to exchange ideas and learnings Renal Nursing Unit leaders across the state meet at least 2 times per year to
collaborate on a state-wide approach to identify patient outcome indicators which has shown to be successful
Doctors are keen to develop their skills to care patients on peritoneal dialysis increase utilisation of private sector, decrease waiting time State-wide referral system term Specialist sonagraphs services in remote and rural regions
Visiting Renal Access Specialist Services (Goldfields and Kimberley) up skilling Dialysis Nurses utilising tri-state agreement (NT, WA, SA) Satellite Haemodialysis Units access portfolio Business Cases increase Full Time Equivalent RASS regionalising peritoneal dialysis initiation remote area scoping Armadale Kelmscott Health - central line insertions monitoring of access Kimberley Aboriginal Medical council adopted team approach to renal access – Bega,
Nephrologists, Diab Educator; podiatrist; pharmacist; dietician Kimberley/ Goldfields CRD roles Armadale developing CKD team SMAHS targeting preventive care ATSI pop increase linkage and Aboriginal Health Service/ A Medical Service GP division care packages Kimberley increase health promotion funding proposal for Renal Regional Teams tele-health State Strategic planned and funding proposal.
What needs to be done?
Establish the Palliative / CKD clinic CKD MoC recommendation adopting the model the St Vincent’s model NSW.
Look at a standardised approach and resourcing to vascular line insertion. Align expertise around management of renal and dialysis patients. Provide greater education for rural staff so that they can inform patients of their
management needs and requirements so that they can make greater informed choices about care and access to such.
Expand the multidisciplinary CKD clinics. Allow GP’s to make referrals to CKD clinics. CKD clinic requires executive support from hospital CE’s. Support data collection and analysis from the CKD clinics to demonstrate their
effectiveness Develop trust and respect amongst the multidisciplinary team of radiologists, nurses,
and doctors. Implement the CKD MoC vascular access pathway to achieve timely referral practice to
increase the number of patients with functional fistulas. Increase support for the vascular access procedures – increase in theatre time, beds,
surgical workforce and make these procedures a priority Improve patient outcomes by a pro-active management of CKD patients by pre dialysis
and access nurses in a CKD clinic environment rather than the ad-hoc management in a hospital setting.
Increase specialised RA surgery services to rural/ remote Increase Full Time Equivalent staff
Decentralise Peritoneal Dialysis care Decrease waitlist Train Aboriginal Health Workers Introduce prioritisation of patients on waitlist i.e. on haemodialysis via CVC Up skill of other medical professionals in access surgery - Arterial Venous Fistula/ CVC Develop state-wide protocols for CVCs care Utilise peripheral hospitals for access surgery
Domain 4: Palliative Care
What How Who When
Redefine CKD – Palliative Care Service
Definition of criteria for referral to Palliative care services.
Refine KPIs – Quality of Life, Patient/ Carer Satisfaction survey; Staff satisfaction survey; % AHD, knowledge of Palliative Care Community
Educate community regarding above.
Research & Modify existing CKD – Palliative care pathway
Require support and recognition by executive
Need to be credential and endorsed
Promotion – talks via GPs; Posters; Kidney Health Week; WARES
Multidisciplinary Working Group and consumers and carers – tap into existing groups WA Health Kidney
Australia AMS Nurse Education
Now
Individual
Find out the resources you can access. Ensure veryone knows what resources they have – central point for resources. Own education Local education sessions/ support groups
Organisation
Education for nephrologists/ renal nurses. Pathway from Stage 3/4/ part of care plans Policy that all have AHCD (KPI is %) NFR documentation for all (KPI is %) Specialist training for a % nurses/ Doctors - ?KPI
Project person Who: Senior Nurse 6/12 Seeding project
When: ASAP Where: Pilot tertiary centre
Measures:
timely withdrawals satisfaction survey (relatives) % with AHCD/ NFR etc % not commencing/ not on dx short time reduced hospitalisation rates
What needs to be done?
Some change thinking of renal staff. Multidisciplinary Team approach Support from key leadership Collaboration Promote modern palliative awareness and ethos Education Standard mandated palliative care pathway/ model Advanced Care planning Clinic consists of:
- Renal SRN - Renal Palliative Physician
How?
Adopt palliative St. George model from NSW Develop implementation plan and adjust for W.A. State wide implementation of model
– led by the tertiary institutions - Staged approach to implementation Consider a pilot program Modify for rural sector
Measurements
Use the measurements from St. George and benchmark with them. Benchmark with palliative management in Cancer.
With Whom
Palliative Care Team St. George NSW Area Health Service WA Country Health Services (WACHS) Parallel with CKD clinic Diabetes services Renal Network Working Party Engagement with all stakeholders
Consumer and Family
When
- Working group from this meeting - R. Barret - J. Hoskin - S. Porter - L. Ekstrom - Business Manager - Business plan to SHEF by December 2011 - Clinicians x 3 - 2 meetings in next P/12
Other feedback
What has been done
GPs do own palliative care- 1800 number KHA educational material – 1800 number in Armadale Hospital: patients given information on Advanced Health Care Directives Not For Resuscitation (NFR) for renal dialysis – order stands for 3/12 and reviewed by
nephrologists at clinics In SJOG Bunbury: patients have access to palliative care Kimberley Aboriginal Renal support Service has palliative care pathway and staff meet
monthly to review at SCGH and Fremantle nephrologists more willing to accept palliative care pathway working group across chronic networks
What needs to happen
culturally appropriate education. education for health care workers pre-dialysis education and referral renal specific education materials earlier discussion of palliative care and allow patients to choose no dialysis option book longer appointments to have discussions. Patient needs to have good information
and education and participate in decision making discussion on quality of life issues NFR to be long standing for all hospitals or tight renewal system palliative care/ pain, clinic staff education and local clinics needed in the South West
and Kalgoorlie replicate Kimberley model care plan to include palliative care and on-going support Liverpool care pathway for end of life care Palliative care in nephrology course
Change focus from just cancer Address implications and what it means to start dialysis. Driven by “markers” “criteria” referral pathways. Pathway recognised and supported by nephrologists. multi disciplinary team involved in decision making.
Advanced Health Care Directives (AHCD):
People aware in the background. - Private sector - use own education pathway and have own ACD.
introduced by GP when going to nursing home. consumer did it with GP. not enough education –need more renal consumers unaware. discussions to include donation notification to satellite for NFR simplify document E-health critical
Domain 5: Workforce
Current situation
Kimberley – Education on site (renal nurses) Rockingham General Hospital has O.2 FTE (Full Time Equivalent)consultant – difficult
to obtain further support Dialysis care assistants
- None (competing with nursing board) - Not specific for Renal
No Aboriginal Health Workers Communities not set up to deliver standard of required care
What needs to be done?
Integrate in Price Per Treatment (PPT) for dialysis a model for identifying numbers of Doctors – funding model.
Recognise shortage of Doctors in specific areas. link with increase in nurse practitioners/ alt. workforce (renal technician) Numbers of Doctors Population per Full Time Equivalent (Bench marks)
Train Renal GPs. (especially rural) o Quality and safety (Buddy system)
Formalise of renal support for rural registrars. Improve and enhance services e.g. CKD clinics
Provide incentives to renal trained GPs/ Nurse Practitioners/ Aboriginal Health Workers to work in rural/ remote areas
Decentralise CKD clinics in the community Formalise Aboriginal Health Workers education and offer incentives and scholarships Incorporate CKD into Chronic Disease Management Make more use of telemedicine/ tele-health Increase education (supported) for nurses, Aboriginal Health Workers; Doctors;
Registrars Introduce rural/ remote placements for registrars
Key Performance Indicators:
1. Decrease in number of referrals to tertiary centres (e.g. from rural) 2. Decreasing waitlist in tertiary. 3. reduced late referrals
General (Doctors and nurses) + Aboriginal Health/ Aboriginal Health Workers
Increase awareness and access to Medicare items for Chronic Disease Management Follow up renal teams (Nursing model →Aboriginal Health, etc) including closing the
gap. (Aboriginal Health Workers training). Resource positions e.g. renal support nurse and senior nurses in GP practices. need models from people already there (Renal Plan has identified some of this) Nurse could be managing groups of conditions. Where could this fit in nurse practice model and training? Extension of community
nursing roles? Ensure continuous professional development and maintenance of skills e.g.
videoconference use. Increase communication between WA Country Health Service (WA Country Health
Service (WACHS)) sites. Relieving models – allow swaps. WA Country Health Service (WACHS) needs to develop Enrol Nurses roles in renal Central WA Country Health Service (WACHS) person as anchor –person Above recognises need for increase of nurses and Aboriginal Health etc Making renal attractive!!
What needs to happen
Review licensing requirements for home dialysis in relation to carers Review contracts for home therapy program Standardise contracts to include AH (Aboriginal Health Workers and medical Full Time
Equivalent/ patients ratio Rural “centres” to have resident specialist or physicians with specific interest. Nurse Practitioners to work where physician’s shortage exist (rural/ remote) Adequately define and monitor contract management Reassessing for training “unskilled” nursing staff Retention—job satisfaction/ remuneration
Rotation of Satellite Dialysis Unit (SDU) nurses to tertiary committees Review scope of practice of NP (Definition of role/ prescribing) by the DoH
New grad nurses rotating in AD
work experience (BP/weight ) Enrol Nurse (TAFE) (Stirling) Aboriginal Health Workers at centres with high prevalence of ATSI Loss of Skill of Renal Nurses (Peritoneal Dialysis) and medical Develop education pathway and train renal GP Buddy system nephrologists – Nurse Practitioner Aboriginal Health Workers – Dollars!!! Training of alternative renal staff (assistance in nursing) WA Country Health Service (WACHS) to support standardised, globally accepted
curriculum Better collaboration private/ public sector in WA Country Health Service All graduates to go through HD, sufficient experience
Appendix 5 Evaluation report renal forum May 2011 Forum Evaluation Results
Attendees were invited to provide feedback about the Forum by completing a short evaluation form. The form was completed by 73% of attendees.
Why respondents attended
The most frequently cited reason for attending the renal forum was to ‘network’. Respondents explained ‘networking’ as the opportunity to:
Share ideas, information, understandings or concepts Promote specific services or models of health service delivery Advocate for specific patient or carer groups Learn more about the renal health ‘system’ Meeting others face to face Have informal ‘side discussions’ during lunch and afternoon tea breaks
Many respondents stated that they attended the forum to broaden their knowledge of renal health issues and/or service delivery planning. For some, attendance at the forum perceived as a way of ‘staying up to date’ with renal health care issues and the direction of renal health reform. As one participant commented, the forum was an effective way to learn about ‘What's going on? Where are we headed? What part can I play?’
Respondents were also motivated by a desire to ‘have a say’ and influence the direction of renal health initiatives in WA, most commonly to advocate for a particular issue, patient or client group or organizational agenda. A small number of respondents were motivated to attended ‘to ensure a range of perspectives is heard at the forum’.
How respondents rated the Forum
Respondents rated a) their overall satisfaction with the Forum and b) their level of agreement with four statements that described specific elements of the Forum. The results are displayed in Figures 1-5 below.
Figure 1. Overall satisfaction with the Forum
Rate your overall satisfaction with the Forum
4%4% 22%
70%
Very DissatisfiedDissatisfiedNeitherSatisfiedVery satisfied
Figure 2. Forum focus
The Forum focused on important issues
40%
58%
2%
Strongly DisagreeDisagree Neither AgreeStrongly Agree
Figure 3. Opportunity to contribute
I was given the opportunity to actively contribute
4%
40%
56%Strongly DisagreeDisagree Neither AgreeStrongly Agree
Figure 4. Implementation issues
Workshop 1 enabled participants to identify Model of Care implementation issues
12% 19%2%
67%Strongly DisagreeDisagree Neither AgreeStrongly Agree
Figure 5. Implementation priorities
Workshop 2 enabled participants to identify Model of Care implementation priorities
13%4%
15%
68%
Strongly DisagreeDisagree Neither AgreeStrongly Agree
What respondents found most valuable
When asked what they found most valuable about the Forum, almost half of the respondents reported ‘networking’. Respondents valued the opportunity to share ideas and perspectives, and to discuss and clarify issues face to face across a broad range of stakeholder groups.
Many respondents valued the two way flow of knowledge and information at the Forum. Respondents placed a high value on the having the opportunity to contribute whilst also gaining exposure to a range of ideas and knowledge contributed by others, ‘to inform and be informed by others’.
Participants valued the opportunity for ‘interdisciplinary collaboration’ and commented that this collective knowledge approach was a particularly effective way to identify
Service delivery issues Service delivery ‘solutions’ Strategies for implementing solutions
A large number of respondents valued the focus on action. They particularly valued the setting of specific targets and goals and the identification of strategies for implementation.
Respondents also valued the formal presentations.
What respondents found least valuable
When asked what they found least valuable about the Forum, less than half of the respondents were able to identify anything that they valued least. The majority of respondents either left the question blank, wrote ‘nil’ or ‘nothing’, or provided positive feedback such as ‘ it was all good’.
Elements of the forum cited as least valuable included:
Limited time. Respondents commented that the Forum ‘seemed rushed’, that the time at tables ‘was short, sometimes extremely short’.
Voting/prioritisation system. A small number of respondents stated that the prioritisation exercise did not add value, that ‘asking for three preferences wipe(d) out other important things’ and ‘impeded some good constructive efforts being expanded’.
The venue and parking for the venue were criticised by a small number of respondents. ‘Please support venues that promote health, not football’ and ‘where one can park without fear of being fined’.
A small number of respondents believed that the stakeholder representation was skewed. These respondents suggested that some stakeholder groups were overrepresented (eg. dialysis staff), whilst other important groups were under-represented (eg, GP’s, ‘on the ground workers’ and Aboriginal Health Workers).
Suggestions to improve future events
The following were suggested as ways to improve future events
Allow more time for debate and discussion of issues Provide pre-reading and identify other ways that attendees could prepare for the Forum Reduce the amount of ‘movement’ in the room. A small number of respondents
reported that the logistics of moving table to table was ‘confusing’ and ‘disruptive’. Use ‘good news stories’ to help attendees identify strategies that are more likely to work
in the ‘real world’ Provide attendees with a clear indication of how and when feedback from the Forum will
be disseminated. A greater emphasis on prevention, early detection and slowing the progression of
Chronic Kidney Disease.
