Public consultation on better outcomes for people with chronic and complex needs through primary health. 6 August September 2015

Transcription

1 Public consultation on better outcomes for people with chronic and complex needs through primary health 6 August September 2015 INTRODUCTION The Australian Government is inviting you to contribute to the reform of the health system and delivering a Healthier Medicare. One of the priority areas is better supporting people with chronic and complex health conditions, including mental health conditions, through primary health care. This survey has been announced alongside the release of a Discussion Paper by the Primary Health Care Advisory Group, to examine options for health reform and provide a report to the Australian Government in late Your responses to this survey will inform the Primary Health Care Advisory Group and help determine how to best improve the primary health care system. Additional information on Healthier Medicare, the Primary Health Care Advisory Group and this survey are available via the Department of Health website. Thank you for taking time to participate in this important opportunity to shape Australia s future health system. This survey is hosted by ORC International, an independent research company. In the course of this research, ORC International will store data in Australia and the United States on secure servers that comply with Australian Privacy Law. At any time during the survey, you may select to save your responses to return to at a later time. To do this, click the Save to return later button located towards the bottom left of the page. You will be asked to provide an address, to which a return link will be sent. Throughout the survey, blue font indicates that a definition is provided. Hover over a phrase in blue to display its definition. Where comments are requested, please limit each of your responses to 2250 characters or less (approximately 300 words). However, up to 3750 characters (approximately 500 words) can be entered in the final question which provides you with an opportunity to add any additional comments you may have. For any questions about the hosting of this survey, please PHCAG_Consult@orcsurveys.com. DEMOGRAPHICS D1. First we would like to ask some questions about you and your organisation, if relevant. This information will help us analyse responses; however, any question you prefer not to answer may be skipped. Are you responding as an individual, or as a member of an organisation? Page 1 of 15

2 If you work within a peak body or health care organisation, please indicate whether you will be primarily answering from an individual or organisational perspective. Individual 1 Organisation 2 D2. Are you : Male 1 Female 2 Other 96 (IF D1= Organisation) D3. To which of the following categories does your organisation belong? Please select one, main category only. Aged care 1 Allied health 2 Consumer 3 GP/ medical practice 4 Hospital 5 Indigenous health 6 Local/ state government 7 Mental health 8 Nursing 9 Primary/ community health 10 Primary care research 11 Primary health network 12 Private health insurer 13 Women s health/ men s health/ chronic disease 14 Other government 15 Other non-government 16 (IF D1= Organisation) D4. What is the name of your organisation? National Rural Health Alliance Page 2 of 15

3 (IF D1= Individual) D5. Do you have a diagnosed chronic or complex health condition? (IF D1= Individual) D6. Do you care for someone with a chronic or complex health condition? (IF D1= Individual) D7. Are you a health care practitioner? (IF D7= Yes) D8. Which of the following best describes your primary role as a health care practitioner? Please select one, main role General practitioner (GP) 1 Dentist 2 Nurse 3 Diabetes educator 4 Aboriginal health worker 5 Pharmacist 6 Chiropractor 7 Dietician 8 Exercise physiologist 9 Occupational therapist 11 Physiotherapist 12 Podiatrist 13 Psychologist 14 Social worker 15 Speech pathologist 16 Other allied health professional 17 Page 3 of 15

4 D9. Are you a practice manager? (IF D1= Individual) D10. Are you Aboriginal or Torres Strait Islander? (IF D1= Individual) D11. Do you speak a language other than English at home? D12. What is your postcode? The NRHA is a national organisation. All responses to this survey will be aggregated for reporting. It can also be useful to include individual example comments in reports. D13. Do you? SR Consent to your comments being quoted in reports, as long as you, or your organisation, are not identified 1 Consent to your comments being quoted in reports, as long as you are identified 2 Not wish to be directly quoted in reports 3 (IF D13= Consent and ARE to be identified) D14. If quoted in reports, what is the name you would like any of your comments to be attributed to? National Rural Health Alliance Page 4 of 15

5 SECTION 1 - OVERALL Q1. What aspects of the current primary health care system work well for people with chronic and complex health conditions? If you can see a GP or other PC professional in good time, can be referred without delay and as necessary for follow-up interventions and tests (pathology, imaging, more specialised clinicians), have a high level of health literacy, live in circumstances that are not too challenged by the social determinants of poor health and can afford all the necessary follow-up, then your chronic disease can be well-managed and its dleterious effects minimised. Unfortunately, however, few of these circumstances are assured for people in rural and remote areas. Q2. What is the most serious gap in the primary health care system currently provided to people with chronic and complex health conditions? a) In your area? N/A b) Nationally? The most serious gaps in the primary care system in rural and remote Australia relate to: poorer access to primary care generally (as evidenced by the major underspend on Medicare funded services in these areas); the declining prevalence of doctors with increasing remoteness; the declining prevalence of dentists and allied health professionals with increasing remoteness; fragmented patient pathways; and lack of 'fit' of health service models. In terms of specific chronic conditions, the most challenging are: mental illness; diabetes and obesity; and cardiovascular disease. Q3. What can be done to improve the primary health care system for people with chronic and complex health conditions: a) In your area? N/A b) Nationally? Some opportunities to improve the primary health care system for people with chronic and complex health conditions in rural and remote Australia include: recognition of the poorer health outcomes, and the higher costs of services, in rural and remote areas in the allocation of resources; Page 5 of 15

6 recognition of the need to address the social determinants of health first and foremost; aligning distribution of the health workforce more closely with need; enhancing the team-based capacities of the rural and remote health workforce; fostering more widespread engagement in ehealth/telehealth; 'rural proofing' in the development and implementation of all policies and programs. Q4. What are the barriers that may be preventing primary health care clinicians from working at the top of their scope of practice? Rural and remote GPs tend to work longer hours. This is because there is greater health need in rural areas due to the higher prevalence of risk factors and chronic diseases. Also, rural GPs are often required to perform a broader range of tasks because other health professionals are frequently not available. Rural and remote nurses tend to work longer hours. In rural and remote areas, nurses are often the first point of contact for a range of primary care functions that, in metropolitan areas, would normally be provided by GPs, specialists and allied health professionals. In these communities, nurses often act as sole primary care providers and are frequently required to extend their skills due to the diverse health needs of their community and the lack of any other form of health personnel support. Other barriers that may be preventing primary health care clinicians from working at the top of their scope of practice include: challenges in accessing training and continuing professional development; challenges in accessing locums; concerns about personal safety, particularly when working in isolation; lack of appropriate remuneration; and lack of social support, especially child care, and appropriate education. SECTION 2 THEME 1, EFFECTIVE AND APPROPRIATE PATIENT CARE As described in Theme 1 of the Discussion Paper, a health care home is where patients enrol with a single provider which becomes their first point of care and coordinates other services. Q5a. Do you support patient enrolment with a health care home for people with chronic and complex health conditions? Q5b. Why do you say that? The NRHA does not have an agreed position on the matter. However, we are aware of a number of US studies which have shown a very significant reduction in avoidable hospital Page 6 of 15

7 admissions, length of stay in hospital and use of the emergency department following the adoption of the healthcare home model. And the two areas where the benefits are most apparent are those that are likely to put most pressure on Australia s health system in the future: aged care and the management of chronic disease. Q6a. Do you support team-based care for people with chronic and complex health conditions? Q6b. Why do you say that? A collaborative, multidisciplinary approach is needed to effectively address chronic disease. Such an approach is actually reflective of the nature of clinical care in rural and remote areas. Workforce shortages and mal-distribution are the main constraints. The Multi-Purpose Services (MPS) program supports team-based care. The MPS program is a joint initiative of the Australian and state/territory governments. By pooling state and Commonwealth program funds, MPSs deliver integrated health and aged care services to small rural communities that would otherwise be too small to sustain stand-alone hospitals or residential aged care facilities. The range of services offered by each MPS varies according to local need, but may include: residential aged care, acute care, subacute care (including respite and palliative care), emergency, allied health, oral health, primary health, and community services. A key feature of the MPS program is that it allows smaller communities to consolidate services, better match services to community needs, recruit and retain staff, and minimise administration overheads. The Multi-Purpose Service (MPS) program should be expanded and strengthened by: Commonwealth Government capital funding to establish new MPSs across rural Australia (a large proportion of this should be used to assist existing state-owned health facilities to transition to the MPS model); and tasking the Rural Health Standing Committee of Australian Health Ministers' Advisory Council to: o develop nationally consistent eligibility criteria for MPSs; o make recommendations to improve the financial sustainability of existing MPS; and o develop a plan for better integrating services provided through MPSs (including for aged care), Primary Health Networks, the National Disability Insurance Scheme, and state-based community and primary care services. Page 7 of 15

8 Best practice multi-disciplinary care must be supported by multi-disciplinary training and learning. The NRHA has long supported the shift to multi-professional learning across the healthcare disciplines. Multi-disciplinary learning introduces practitioners to team management at an early stage, at the undergraduate level, and continues through to the postgraduate level. Learning in such a way equips students for multi-disciplinary practice once they graduate. The University Departments of Rural Health (UDRH) are currently involved in developing and implementing inter-professional education programs for health students in rural and remote Australia. Approaches vary between UDRHs but all have a strong multidisciplinary focus in their education and training programs. The NRHA is concerned that workforce initiatives tend to focus simplistically on student placement and training opportunities and would urge the need to consider a more broad approach in which the wider rural health sector, including consumers, is engaged. A third option might be Introducing bundled payments for the prevention and management of common chronic diseases. Consideration should also be given to expanding this to some of the less common chronic diseases. This may take the form of providing a single, lead provider (for example, a GP) with a single payment to cover the costs of providing a course of care (for example, management in the first year of a newly diagnosed diabetic). Bundling payments along these lines would give the lead provider the flexibility to fund the chronic disease care required by an individual patient. One patient may, for example, need intensive treatment from a dietitian and only occasional visits from a podiatrist. Another may need the support of a diabetes educator and treatment for an exercise physiologist. Bundled payments encourage team based care and collaboration among health professionals, which is vital to providing best practice chronic disease care. Q7. What are the key aspects of effective coordinated patient care? Please number in order of importance. Care coordinators Patient pathways Patient participation other (SPECIFY) 96 Q8a. How can patient pathways be used to improve patient outcomes? By tracking a patient pathway it is possible to identify problems relating to the timeliness of care and intervention; communication between different providers of care; cost and time imposts on the patient (eg travel); the adequacy of infrastructure (eg for virtual communications); and continuity of care (eg in relation to medicines). Page 8 of 15

9 The Primary Health Networks have an important role to play in streamlining patient pathways. One of their roles will be to customise health promotion and chronic disease prevention programs for local communities. Given the well-established relationship between socioeconomic disadvantage, health risk behaviours and chronic diseases, governments should also be facilitating opportunities for agencies in housing, employment, and education to work together in coordinating patient pathways. Given the large size of some of the new PHNs, there is considerable uncertainty about how they will coordinate patient pathways at the local level. Their chances of success will be greatly enhanced if they work collaboratively with existing Multi-Purpose Services (MPSs). Many MPSs have over 20 years' experience co-ordinating health and other services in local communities. PHNs should identify ways of working with existing MPSs and enhancing the work they are already doing to prevent and manage chronic disease. One option could be for PHNs to establish a hub and spoke model, with the MPSs acting as a spoke. Alternatively, PHNs could consider commissioning MPSs to be service providers in areas where they are already operating. Q9. Are there other evidence-based approaches that could be used to improve the outcomes and care experiences of people with chronic and complex health conditions? Our particular interest is such people who live in rural and remote areas. There have been many trials and evaluations of care programs for people in rural and remote areas with chronic and complex health conditions, but no central repository for this information. The information is strewn across medical- and health-related journals, evaluations of programs published on countless websites, and other mediums. A readily accessible repository of policy and program evaluations could guide policy makers in their design and implementation of policies and programs (by learning from the successes and failures of others). HealthInfoNet is a good example of such a repository which specialises in on the health of Aboriginal and Torres Strait Islander people. SECTION 3 THEME 2, INCREASED USE OF TECHNOLOGY Q10. How might the technology described in Theme 2 of the Discussion Paper improve the way patients engage in and manage their own health care? Much is expected of the capacity of technology to overcome some of the effects of the tyranny of distance, including for self-care of a patient. However virtual interfaces should not be seen as an or adequate replacement for face-to-face care. Technology provides many means for the transmission of data and information. It is particularly important that people in rural and remote areas have access to information (and guidance on how to use this information) on the risk factors that contribute to chronic conditions and how one can self-manage their condition(s). Page 9 of 15

10 This could take the form of online resources, presented in a way which is relevant to their specific audience (e.g. people in rural and remote areas). This could be complimented by a helpline-type service, staffed by health professionals. An example of this might be a website offering information and resources on preventing and self-managing diabetes, complimented by a helpline staffed by diabetes educators. Q11a. What enablers are needed to support an increased use of the technology described in Theme 2 of the Discussion Paper to improve team based care for people with chronic and complex health conditions? Equal access to broadband and telecoms connectivity, including at equal prices. Internet connectivity to support communication between health professionals. Mobile coverage to support communication between health professionals. More widespread adoption of the personally controlled electronic health record (MyHealth). Financial incentives to encourage engagement in ehealth/telehealth. Education around the applications of ehealth/telehealth in team-based care. Q12. How could technology better support connections between primary and hospital care? ehealth/telehealth can allow health professionals in more remote areas to confer and collaborate with health professionals in regional- or city-based hospitals. For example, a remote area nurse might seek guidance from a dermatologist in a city-based hospital about treating a patient who has been burned. Q13. How could technology be used to improve patient outcomes? Telephone/smart technology can increase the support available for rural and remote patients with chronic disease: o Researchers from Monash University in Melbourne found that rural and remote patients with heart failure benefited when they received telephone support to help them manage their condition, along with follow-up from a trained cardiac nurse. These patients had fewer hospitalisations than patients who did not receive telephone support, which suggests this relatively lowcost intervention might be a valuable adjunct to face-to-face care for rural and remote patients. o In 2013, the Royal Flying Doctor Service (RFDS) Victoria commenced its Diabetes Telehealth Service. The Service is based in Mildura where there is no resident diabetes specialist. Like most, if not all, of country Victoria, there is a growing incidence of diabetes in the region. Hosted by Monash School of Rural Health in Mildura, local diabetes patients are connected with endocrinologists from Baker IDI Heart and Diabetes Institute in Melbourne. Trial appointments began in November 2013, with the full Service launched Page 10 of 15

11 in May Fifty-one appointments were completed before the end of the financial year. o The Royal Flying Doctors Service (RFDS) 24/7 remote consultations service compliments face-to-face services. RFDS medical practitioners provide a 24/7 telephone and radio medical consultation service to people living, working or travelling in remote and rural Australia. Over 85,000 consultations are conducted nationally each year. Advice is given to rural doctors, remote area nurses, allied health staff, Aboriginal and Torres Strait Islander health workers and patients, their carers and family members. SECTION 4 THEME 3, HOW DO WE KNOW WE ARE ACHIEVING OUTCOMES? Q14a. Reflecting on Theme 3 of the Discussion Paper, is it important to measure and report patient health outcomes? Q14b. Why do you say that? Baseline data and information are needed for improvement of the system. It is important to measure and report on patient health outcomes to identify those policies and programs which are effective (so that they can be replicated) and those that are not (so resources they can be avoided). Q14c. How could measurement and reporting of patient health outcomes be achieved? Organisations like the Australian Bureau of Statistics, the Australian Institute of Health and Welfare and the National Health Performance Authority play an important role in providing impartial, comparable information about health outcomes across regions. The Primary Health Networks too have an important role to play in measuring patient health outcomes. It is important that these organisations are adequately resourced to employ or contract a range of experts such as epidemiologists and population health experts to carry out this function. Small area data on (changes in) health status, response to interventions, medicines etc needs to be available. Q15. To what extent should health care providers be accountable for their patients health outcomes? Page 11 of 15

12 To a considerable extent. Q15b. How could health care provider accountability for their patients' health outcomes be achieved? Through tracking individual patients' and population group health status, including by place, remoteness, region, community). Q16. To what extent should patients be responsible for their own health outcomes? Patients should be provided with sufficient information to enable them to make informed decisions about their health. Those with the capacity to do so ie with high levels of education, sufficient income, social engagement and skills, should be encouraged by every means to care for their own health. Q16b. How could patient responsibility for their own health outcomes be achieved? It is important that people in rural and remote areas have access to information on the risk factors that contribute to chronic conditions (so that they can be prevented), as well as how to self-manage their condition(s). CDSM is important and should be supported - with the understanding that some people have greater resources and capabilities for this than others. This might take the form of online resources, presented in a way which is relevant to their specific audience (e.g. people in rural and remote areas). This could be complimented by a helpline-type service, staffed by health professionals. SECTION 5 THEME 4, HOW DO WE ESTABLISH SUITABLE PAYMENT MECHANISMS TO SUPPORT A BETTER PRIMARY HEALTH CARE SYSTEM? Q17a. Theme 4 of the Discussion Paper discusses different payment mechanisms. How should primary health care payment models support a connected care system? If you prefer a blended model, as described in Theme 4, select all the components that should apply. Capitated payments 1 Salaried professionals 2 Pay for performance 3 Fee for service 4 Other (SPECIFY) 96 17b. Why do you say that? It's complicated! No single answer, but mixed modes, 'fit for purpose'. Page 12 of 15

13 Q18a. Should primary health care payments be linked to achievement of specific goals associated with the provision of care? Not clear what is meant. 18b. Why do you say that? Q19. What role could Private Health Insurance have in managing or assisting in managing people with chronic and complex health conditions in primary health care? The potential for private health insurers to be involved in chronic disease prevention and management in rural areas is relatively limited because the rate of private health insurance decreases with remoteness. In , rates of private health insurance (using selfreported data) was 57 per cent in major cities, 48 per cent in inner regional areas, and 41 per cent in other areas (which includes outer regional, remote and very remote areas) (37). For those people in rural and remote areas who do have private health insurance, opportunities to benefit from it can also be limited. Programs that rely on internet connectivity for example, health coaching programs can be difficult to use for people in rural and remote areas where there is poor connectivity. Similarly, programs that rely on face-to-face access to health professionals or other health workers can be problematic for people in some rural and remote areas. Because the uptake of private health insurance is lower in rural and remote areas, the Alliance urges governments to give priority to publicly-funded, evidence based, chronic disease prevention and management programs. If investment is made in privately-funded programs, many people in rural and remote Australia the people who tend to have the greatest need for them will be unable to access them. The consequence will be greater disparities in health outcomes between city and country people. Q20. Do you have anything you would like to add on any of the themes raised in the Discussion Paper? We look forward to the chance to make further inputs. THANK AND CLOSE Thank you very much for taking the time to take part in this consultation. This research is being conducted in keeping with the Australian Privacy Principles and the industry Privacy Code. ORC International s privacy policy is available on our website ( Page 13 of 15

14 Definitions Phrase chronic and complex health condition top of scope of practice health care home patient pathways patient participation care coordinator capitated payments salaried professionals Definition text Chronic and complex health condition is a term applied to a diverse range of diseases, such as heart disease, cancer, arthritis and mental illness where symptoms are long-lasting and persistent. Although these features also apply to some communicable diseases (e.g. infections), the term is usually confined to non-communicable disease. Top of scope of practice means using the skills that they are educated, competent and authorised to perform. A health care home is where patients enrol with a single provider which becomes their first point of care and coordinates other services. Patient pathways are nationally or regionally standardised, evidence-based multidisciplinary management plans which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for a patient group. Patient participation refers to shared processes in which both the patient and health professionals contribute to medical decisionmaking and care planning. It requires health literacy, selfmanagement, self-awareness, collaboration and empowerment of patients in decisions regarding their health. A care coordinator refers to a role or a specific person responsible for organising patient care activities and sharing information among participants concerned with a patient s care to achieve safer and more effective care. Capitated payments or capitation is a way of funding health services. Providers are paid a set amount per enrolled client or resident of an area, per time period often monthly, quarterly or annually. Salaried professionals are employed and paid independently of their productivity or their patient s outcomes. This way of funding health services is often combined with expected standards of performance for health professionals and also incentives such as pay for performance. Page 14 of 15

15 Phrase Definition text pay for performance Pay for performance is a way of funding health services. Providers receive payment for delivering certain types of care or achieving specific outcomes for their consumers, typically related to quality of care, access to care, patientsatisfaction measures and service provider productivity. fee for service aspects patient enrolment team based care Fee for service is a way of funding health services, similar to other types of retail transaction. Providers are paid a fee based on the services they provide to consumers, usually based on the time taken to deliver the service, effort or cost. Timeliness, cost and appropriateness of care Patient enrolment involves the patient agreeing to see on an ongoing basis the health provider/s of their choice. Team based care is the provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centred, timely, efficient, and equitable. Page 15 of 15