Reducing the incidence of VLU by 50% in 5 years

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1 Wound Awareness The Challenges The Solutions Everyone Deserves Intact Skin and the Sense of Wellbeing Reducing the incidence of VLU by 50% in 5 years SIMPLY-It wont happen without General Practice General Practice is at the coal face of VLU management General Practice is the gatekeeper for our medical system KPMG report are 42,600 VLUs at any one time 86% of the time GPs are involved in the care of a chronic VLU Wound related procedures are the 2 nd most frequently billed procedure in GP [BEACH study]

2 The Basic Principles for Management of Chronic Wounds 1. Evaluation of Ulcer Aetiology 2. Treatment of Underlying Cause 3. Management of the Wound 4. Monitoring and maintenance of healing of Wound To reduce the incidence of VLU by 50% in 5 years the potential lies in General Practice broad skills and training of GPs and practice nurses the vital and expanding role of the practice nurse with improved trust and collaboration with GPs emphasis on chronic disease management [Medicare funding] access to a multidisciplinary team of allied health professionals and specialist care [Medicare funding] long standing collaboration with community nursing and aged care long standing relationships with patients engender trust, caring and empathy and allow assessment of wellbeing and ensure wellbeing is the principal focus of care

3 Problem 1 -Wound Awareness The Human and Financial Cost The financial cost-kpmg study The human suffering: -mortality associated with chronic wounds similar to many cancers in our community -affecting society s most vulnerable wounds are disproportionately represented in the elderly and in the lower socio-economic community -more than 25% of residents in Aged Care have a wound 5 year Mortality -International Wound Journal 2007

4 Problem 2 Practising Evidence Based Wound Care Education and Expertise Failure to make a diagnosis of cause of wound Lack of expertise and confidence in performing egabpi and compression bandaging Lack of access to equipment in or out of surgery eg U/S doppler Lack of skills and knowledge of wound dressings, compression bandages, stockings and devices Venous leg ulcer management in general practice -Dr Carolina Weller,Sue Evans 2012 Wound CRC Education Project Report Karen Innes Walker -Project Manager Identifying health services pathways promoting evidence based management of patients with VLUs Finlayson,Edwards et al 2012 Practising Evidence Based Wound Care Problem 2 Education and Expertise Lack of time to assess patient, perform wound care Patients have complex medical needs University medical training lack of dedicated wound management education Limited access for GPs and PNs to guidelines and pathways and education resources Limited access to wound clinics and clinicians and advanced therapies, eg NPWT, in many areas Reluctance for GP to refer for more specialised care

5 Time-The Perennial Problem Wound CRC Education Project Report Results of Provider Study GPs acknowledge wound management is a gap in their knowledge and skills Need for more wound management education and training Identified particular topics of need: -using wound investigations -understanding wound products, pharmaceuticals, and devices Occupational groups with the highest needs are those working in primary care-practice nurses, GPs, aged care workers Skin tears are the most commonly managed wound Least confidence is in management of mixed venous/arterial leg ulcers Preferred methods of receiving education is face to face training and short inservices Karen Innes Walker -Project Manager Prof Helen Edwards -Wound CRC program 3 leader

6 Financial Support Problem No.3 Major costs of wound dressings, compression bandages, stockings and devices Lack of support from all levels of Government can not see the Elephant in the Room Current Medicare subsidy arrangements do not encourage best practice wound care-will the PNIP succeed in wound care? Medicare rule preventing charging for dressings if consultation is bulkbilled Solutions : Problem 1 Wound Awareness Increase wound awareness in general community Recognise Woundol0gy as a speciality Continuing active role of AWMA, Wound CRC Awareness and support from the medical community Support from all professional bodies-racgp, AMA, Nursing and Allied Health

7 Solutions :Problem 2 Education and Expertise Wound CRC education project developing Wound Education Hub, a plan for effective delivery of wound care education and training to medical and nursing students, providers and patients Improve early intervention and reduce recurrence by: -implement NHMRC Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of VLUs and Pressure Injuries -implement specific wound pathways - QUT ihbi, Hunter New England Health Pathways Service provision in the community- Medicare Locals -business model for nurse run wound clinics being developed by Sth Melbourne medicare local -Gold Coast practice nurse wound project. To be expanded next year to GPs, community and aged care nurses Gold Coast Medicare Local/GPGC Practice Nurse wound training project January-July2013 Transfer of learning survey Q3. Overall what impact has the training you attended had on your wound management practice? The training has had no impact on my wound management practice The training has had a slight impact on my wound management practice The training has had a moderate impact on my wound management practice The training has had a major impact on my wound management practice 42.8% 57.2%

8 Gold Coast Medicare Local/GPGC Practice Nurse wound training project Transfer of learning survey Strongly disagree Disagree Agree Strongly agree Neither agree nor disagree As a result of the wound training program, I am now more confident to make clinical decisions regarding the wound management of the patients at my practice 28.6% 64.3% As a result of this training I am now more confident to participate in the wound management decision making process with the GP(s) at my practice 21.4% 71.4% I would recommend this training to other GP Practice Nurses 14.3% 78.6% Gold Coast Medicare Local/GPGC Practice Nurse wound training project Transfer of learning survey We have found a reduction in wound healing time using compression which in turn has increased patient compliance, self esteem & confidence Would love ABPI at work to feel more confident with compression also would like Doctors to be more positive using it. They never want to just because the patient may not like the idea. I had no confidence at all. I know I can now look at wound and see the stage and know what dressing to use Wound healing times and patient confidence has in turn allowed us to order new dressings and to initiate new policies regarding dressings GPs have loved learning from what I have learnt and started using different dressings and asking for my opinion I now suggest to my GPs what I would like to use

9 Gold Coast Medicare Local Practice Nurse wound training project Transfer of learning survey Q 1 : Do you currently use the three layer tubular bandage compression system? Yes 42.8% No 50% No response 7.2% If no what compression system do you use? None Have not had any PT s who have had ABPI done so unable to apply compression therapy Compression stocking We do not do compression other than support bandaging/tubigrip There is no compression system to be used in my practice Only tubigrip one layer Slowly implementing compression therapy into practice Solutions :Problem 2 Education and Expertise If compression is the answer to treating VLUs then make it easier!! Three layer tubular bandage system good results regarding healing and quality of life readily accepted by GPs, nurses and patients-improves compliance less expertise required layers can be removed to improve comfort and compliance bandages readily available and cheaper Dr Carolina Weller et al Randomised clinical trial of three-layer tubular bandaging system for venous leg ulcers Wound repair and Regeneration 2012

10 Solutions :Problem 3 Financial support Review of PNIP Work smarter-make better use of case conferencing, care planning Specific Medicare item number for wound management Recognise woundology as a specialty to allow eg teleconference billing Change of policy from DOHA regarding bulkbilling and paying for products Private Health Funds-more support for outpatient wound care Solutions :Problem 3 National Subsidy scheme for reimbursement of compression therapies and products Implementation similar to national diabetes scheme -diagnosis of VLU and national registration -access to compression devices through pharmacies -access to efficacious application via: General Practices Wound clinics Community clinics-eg Leg Clubs This will require clinicians to provide proof of competancy to maximise safety and efficacy of these devices

11 Once we have done all that then find time 22

12 The Problem on the Gold Coast Gold Coast Health services District Wound Management Model-Carramar Report 2009 The management of patients with chronic wounds in the GCHSD is fragmented and inefficient There are a range of services available but these are poorly coordinated and may not offer optimum levels of efficacy and efficiency Recommendations of Carramar report That a high priority be given to establishing an Interdisciplinary Wound Clinic at the secondary level so that there is an opportunity for referral of chronic wounds in a community setting This service is required to assist those at the primary level to treat hard to heal wounds. It will bring together the necessary expertise form a nurse practitioner, a range of allied health professionals with advanced practise standing, and include review by a medical specialist when necessary Referring to a community based chronic wound management model based on 3 tiers or levels reflecting the escalation in complexity of chronic wounds and the assessment and care that can be provided

13 A change of Practice and an opportunity arises GP Wound Clinic Commenced March 2012 Aimed at secondary level of care to provide an advanced level of assessment and management which is open to the community but preferably by GP referall The essentials to offer General Practice at this level: Assessment and Diagnosis Wound bed preparation- U/S Debridement Management of oedema with compression Management of wound-dressing products Advanced therapies-npwt Multi disciplinary collaboration On site training and education

14 GP Wound Clinic Receiving referrals from : -GPs -community-nurses, Pharmacies -Gold Coast Hospital vascular clinic -Private Hospital Physcians and Surgeons for USWD to inpatients Financial Sustainability How does a private clinic survive? The support of Healthscope-owners and managers of Bundall Medical Centre Practice Nurse Incentive Payments-to support the expanded and enhanced roles for practice nurses to cover the diversity of nurse activities, including but not specifically wound management. Replaced previous item number Working smarter-using Medicare item numbers Patient contribution to cost of products

15 Reducing the incidence of VLU by 50% in 5 years with the General Practice Team The Outcomes of Reducing the incidence of VLU? Wellbeing for All-Especially the Patient

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