Connected hospital networks
Elements we are building from
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What we need to achieve
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The health reforms propose the development of more integrated systems of specialist services.
Currently, within the Southern District, there is a major planning exercise under way for the new Dunedin Hospital and there is a process beginning for developing the Southland Hospital site masterplan. The recent Leena Singh review recommended expansion of the ED footprint at Southland Hospital, as well as more innovative models of care and the potential of an onsite GP service.
Whilst all this activity is underway, there is no clear approach for the shape of a future joined-up specialist services network. Areas where more clarity is required include:
Currently, within the Southern District, there is a major planning exercise under way for the new Dunedin Hospital and there is a process beginning for developing the Southland Hospital site masterplan. The recent Leena Singh review recommended expansion of the ED footprint at Southland Hospital, as well as more innovative models of care and the potential of an onsite GP service.
Whilst all this activity is underway, there is no clear approach for the shape of a future joined-up specialist services network. Areas where more clarity is required include:
- Which tertiary services are provided in Dunedin and which in Christchurch
- Future role and scope of rural hospitals
- Future plan for responding to growing population in the Central Lakes area.
The Southern population experiences the greatest on average distance from secondary or tertiary hospitals.
The map opposite displays the number of people living within an hour's drive of a secondary or tertiary hospital in shades of green. The Central Lakes area is of concern, particularly with the growing population in this area. |
Tertiary services
Dunedin Hospital - The scope of specialist tertiary services at Dunedin hospital and the future roles of Christchurch and Dunedin Hospitals requires further clarification. Defining these roles is likely to be one of the key actions of Health NZ, as it is determining a strategic framework for specialist service provision across the country. There is some urgency for this guidance as it may impact on the new Dunedin Hospital and the approach to service development.
Although Dunedin hospital currently offers most of the subspecialties, a number of them have few admissions, and low numbers of outpatients each year. These specialties will need to ensure there are sufficient patients to sustain their service and continue to attract trainees and maintain an on-call roster.
Getting the mix of subspecialties right, which may potentially involve some specialties being delivered from Christchurch, could free up capacity to use in other services. This might optimise the supply of hospital space and have a workforce which can meet the patient demands.
Although Dunedin hospital currently offers most of the subspecialties, a number of them have few admissions, and low numbers of outpatients each year. These specialties will need to ensure there are sufficient patients to sustain their service and continue to attract trainees and maintain an on-call roster.
Getting the mix of subspecialties right, which may potentially involve some specialties being delivered from Christchurch, could free up capacity to use in other services. This might optimise the supply of hospital space and have a workforce which can meet the patient demands.
Stroke care is an example of how a tertiary service run out of Christchurch can be integrated across other hospitals to provide a consistent service across the majority of the South Island.
These “flight maps” shows where patients from each area across the South attended each of the three tertiary hospitals in a single year (2018) with a diagnosis of stroke. The thicker the bar, the more patients are travelling from that area.
As is seen in the map below, the majority of stroke care for those that live in the South is provided out of Dunedin hospital, with a smaller amount from Invercargill. However, Canterbury also serves the Southern population with a diagnosis of stroke - acting as the tertiary referral centre, receiving the most complex cases. It is noted that the regional stroke service for the Southern region is also provided via telehealth from Christchurch and a similar flight path map would look very different if the contact with service was mapped, not just the final destination.
As is seen in the map below, the majority of stroke care for those that live in the South is provided out of Dunedin hospital, with a smaller amount from Invercargill. However, Canterbury also serves the Southern population with a diagnosis of stroke - acting as the tertiary referral centre, receiving the most complex cases. It is noted that the regional stroke service for the Southern region is also provided via telehealth from Christchurch and a similar flight path map would look very different if the contact with service was mapped, not just the final destination.
Rural hospitals
There are five rural hospitals owned by rural hospital trusts and Lakes Hospital in Queenstown, owned by the DHB. The services provided by rural hospitals vary considerably. They have differing roles in planned and unplanned care for their catchment, offering walk-in onsite clinical services, a variety of inpatient beds (up to 30) and a range of specialist outpatient appointments.
Looking to the future, it would be valuable to review the scope and role of the rural hospitals and the generalist-led services they provide within the context of the role of the hospitals network and how specialist and generalist led services best interact.
Exploring Variation
Overall utilisation
There are different ways that a patient utilises care in each hospital catchment and no rural hospital has similar proportional use by delivery setting. This is exacerbated by inconsistent coding. Within each rural hospital consults are coded differently and this means that it is difficult to truly compare the utilisation of the rural hospitals in the South across all parts of the patient journey. The data used below is that provided by each rural hospital to the Ministry of Health, which is a combination of services provided and purchased.
Most of the events at Dunstan, Clutha and Gore hospitals are outpatients (OP), while Oamaru is similar to the urban hospitals Dunedin and Southland with one third ED and inpatient and the remainder outpatient. Lakes is the opposite to these hospitals – the majority of utilisation is in the ED.
Data also shows that ED events are increasing over time, in most of the rural hospitals, with the exception of Clutha Health First. This Hospital also has the highest proportion of inpatients where the length of stay (LOS) was above 10 days. Unsurprisingly, Lakes District Hospital has the highest proportion of ED attendance from those who are unenrolled in the region.
The similarities and differences in how care is delivered in rural hospitals has arisen from differences in contracts with the DHB and rural hospitals acting independently to meet community priorities. This results in marked variation which impact patients in certain areas who need specific types of care.
There are different ways that a patient utilises care in each hospital catchment and no rural hospital has similar proportional use by delivery setting. This is exacerbated by inconsistent coding. Within each rural hospital consults are coded differently and this means that it is difficult to truly compare the utilisation of the rural hospitals in the South across all parts of the patient journey. The data used below is that provided by each rural hospital to the Ministry of Health, which is a combination of services provided and purchased.
Most of the events at Dunstan, Clutha and Gore hospitals are outpatients (OP), while Oamaru is similar to the urban hospitals Dunedin and Southland with one third ED and inpatient and the remainder outpatient. Lakes is the opposite to these hospitals – the majority of utilisation is in the ED.
Data also shows that ED events are increasing over time, in most of the rural hospitals, with the exception of Clutha Health First. This Hospital also has the highest proportion of inpatients where the length of stay (LOS) was above 10 days. Unsurprisingly, Lakes District Hospital has the highest proportion of ED attendance from those who are unenrolled in the region.
The similarities and differences in how care is delivered in rural hospitals has arisen from differences in contracts with the DHB and rural hospitals acting independently to meet community priorities. This results in marked variation which impact patients in certain areas who need specific types of care.
NB: ED refers to Emergency department; NMDS refers to national minimum data set; OP refers to outpatient; LOS refers to length of stay
Urgent and Emergency care
- Despite being in adjoining TLAs, the way that people access urgent and emergency care is very different between Dunstan and Lakes hospitals. Dunstan Hospital utilises local primary care to provide much of the area’s urgent care, only having emergency care afterhours and when the ambulance and general practitioners are unable to care for the patient in the community. This results in low ED attendances per year, one quarter of that of Lakes District Hospital.
- The number of emergency care visits at Oamaru Hospital falls between Lakes and Dunstan at 8,000 per annum, while Gore and Clutha hospitals have much lower ED numbers due to their size and both use co-located primary care to provide some of the urgent care presenting to their hospitals. Almost all patients attending rural hospital EDs are enrolled with a GP in the catchment, with the exception of Lakes (see graphs above).
Nursing and allied health clinicians make up a large proportion of the workforce of many rural hospitals. A key element of the urgent and emergency care being provided is by experienced nurses, whether that be over phone triage or face to face. Having nurses providing acute care also allows access to their wider skill set. If Rural Hospitals become locality hubs, the interface between the nurses in the hospital and local general practices will become stronger, and the handover of at-risk patients can be more seamless.
The integration of the hospital with primary care seems to allow more manageable emergency care volumes, and having a high level of enrolment supports patients to only be seen when necessary and discharged back to their medical home.
Inpatient care
- In regards to inpatient care, all of the hospitals provide general medical services and rehabilitation, with all but Dunstan and Ranfurly also providing maternity inpatient beds. The majority that are admitted are elderly - even at Lakes Hospital which provides services for the area with the youngest population.
- The admitted population throughout the hospitals has grown over time, especially at Oamaru and Lakes District hospitals. Over half of patients are discharged within 1 day, and half of these stay just one night. 5,800 (15%) of these are 40-64 years. There is a cohort of people who have a length of stay over 10 days and almost all of them are elderly.
The below data shows there is a large group of patients presenting to the rural hospitals who need a brief period of stabilisation through to an overnight stay. Analysis may suggest that some of them can be managed at home with increased supports, especially those who are younger and without comorbidities. This 40-64 year old group with amenable mortality conditions is one of the MoH system level indicators, and would be a good place for this analysis to start. COVID-19 is likely to create prototypes for home monitoring and wearables and these can be used for other chronic conditions, like COPD and heart failure.
Although each hospital provides similar generalist cover, each rural hospital has clinicians (both medical and non medical) with specific areas of interest and expertise. No one rural hospital can provide everything, but the rural hospitals throughout the Southern District could provide a generalist consult service, with teleworking to specialist care at secondary/tertiary hospitals.
With one in ten patients having a prolonged stay in hospital, packages of care may allow earlier discharge to a step-down facility or supported home care.
Outpatient care
- For outpatient care, Dunstan consistently records the highest number of outpatient events, with more specialty options than the other rural hospitals. Oamaru has the next highest number of specialist options, both are in the Dunedin catchment area.
- Although Gore and Balcutha are hospitals with quite discreet, geographically smaller populations, their delivery of outpatient services per capita is different. Lakes has the lowest number of specialists and outpatient appointments per capita, while Ranfurly is not included due to its minimal outpatient activity.
There is a four-fold difference in outpatient use throughout the Southern District between rural hospitals. In comparison with the urban settings, people who live in rural catchments have less access to a range of outpatient services in their area. A substantial amount of the outpatient work done at Dunedin and Southland hospitals is for those who live in one of the rural hospital catchments. Creating more consistent outpatient availability should be a goal for the region, leveraging rural hospital outpatient capacity, telehealth and improved relationships with the tertiary hospitals.
Future direction
Tertiary Referrals
The rural hospitals have indicated they are interesting in providing an extended scope of services to improve system efficiency, provide more care closer to home and reduce demand on Dunedin and Southland Hospitals. This interest should be leveraged.
The system needs to continuously monitor outpatient use by specialty at urban hospitals and formulate ways to treat most of them closer to home. This could include increased access to diagnostics, which the results come available to the specialist and may not then need a consult. This would also include telehealth. Options should be developed to save the patient and their whānau travel time, and improve their experience of care.
- Currently, the rural hospitals have ceilings to the care that they can provide, and patients attend their nominated tertiary facility. These tertiary facilities are up to three hours away by road, and having to travel such long distances negatively impacts on the patients, whānau and communities.
- In 2019 there were on average five patients a day transferred to a tertiary hospital from one of the rural hospital catchments, with over one third being from Lakes and one fifth from Oamaru.
- A substantial amount of the outpatient work done at Dunedin and Southland hospitals is for those who live in one of the rural hospital catchments. Dunedin Hospital outpatients sees 49,000 outpatients a year who live in a rural hospital catchment, and Southland Hospital sees 26,000. The highest use of (publicly funded) outpatients is for ophthalmology, oncology and cardiology outpatient appointments at Dunedin Hospital. At Southland hospital, outpatient nursing clinics are used most often.
- One of the drivers for the transfer from Gore and Balcutha hospitals to their corresponding tertiary hospitals is the access to CT scans. Of all the hospitals, Clutha has the highest proportion of patients presenting to Dunedin are discharged within one day.
The rural hospitals have indicated they are interesting in providing an extended scope of services to improve system efficiency, provide more care closer to home and reduce demand on Dunedin and Southland Hospitals. This interest should be leveraged.
The system needs to continuously monitor outpatient use by specialty at urban hospitals and formulate ways to treat most of them closer to home. This could include increased access to diagnostics, which the results come available to the specialist and may not then need a consult. This would also include telehealth. Options should be developed to save the patient and their whānau travel time, and improve their experience of care.
Generalism
Generalism is supported by the Rural Hospital doctors, giving them specific skills and knowledge to perform interventions or procedures under the supervision of a (usually remote) hospital specialist. Examples of generalism that is currently occurring are seen in obstetric care, anaesthetics, dermatology and gastroenterology. Rural Hospital doctors, like most emergency physicians, are also becoming increasingly proficient in Point Of Care (POC) Ultrasound.
In the future, generalists may be able to play more of a role with birthing in rural areas, including providing necessary anaesthetics and/or delivering via C section. There are international examples that this is feasible. Other generalist care could include other minor ops such as skin lesion removal, and performing gastroscopes and colonoscopies.
Considerations for a review of the scope of rural hospitals:
Central Lakes
Central Lakes is the key growth area in the Southern district. The area (Queenstown, Wanaka, Cromwell, and Alexandra) is growing fast, with an estimated 100,000 people by 2050. Additionally, over the next 20 years, the population of over 65s in this area is expected to increase to two and a half times the 2018 population.
Currently there are many historic and somewhat arbitrary differences between Lakes and Dunstan Hospitals which impact on the delivery of consistent high quality clinical care in the region. The area currently does not operate as an integrated system and there is significant variation around care models and access.
Exploring Variation
Urgent care and ED access
The result of this is that the acute clinical care is different at the two hospitals – and the clinicians need to be more skilled in orthopaedics and medicine at Lakes and Dunstan respectively. The ED at Lakes has the potential to be at capacity especially when there are seasonal peaks and there should be consideration to reconfiguring or increasing its size compared to Dunstan, which has a much more steady and lower presentation rate. In the advent of a COVID-19 outbreak, the Lakes ED may struggle to provide sustainable care with the volume and types of patients frequenting the ED.
- The emergency department at Lakes Hospital is over-utilised, despite there being two private providers of urgent and afterhours care in Queenstown. The patients who attend the Lakes ED tend to be quite a lot younger, of lower acuity and are discharged from the hospital quicker compared to the overall Southern District. 50% of attendances are by those not enrolled with a GP in the region – four times that the regional average which most likely reflects visitors seeking care. This means there is limited organised follow-up for acute injury or illness, and any chronic health issues are difficult to address. Injuries also account for a much higher proportion of patients.
- Dunstan Hospital ED is more similar to the other rural hospitals, supported by relationships with general practice, and providing care for an older population. These older patients are of a higher acuity, having exhausted the care that can be delivered in the community, and are more frequently admitted. Volumes in ED are around one quarter of those seen at Lakes District Hospital ED.
The result of this is that the acute clinical care is different at the two hospitals – and the clinicians need to be more skilled in orthopaedics and medicine at Lakes and Dunstan respectively. The ED at Lakes has the potential to be at capacity especially when there are seasonal peaks and there should be consideration to reconfiguring or increasing its size compared to Dunstan, which has a much more steady and lower presentation rate. In the advent of a COVID-19 outbreak, the Lakes ED may struggle to provide sustainable care with the volume and types of patients frequenting the ED.
Inpatient care
- Despite being in the same TLA, people who live in Queenstown and Arrowtown are admitted to Lakes Hospital and those in Wanaka, Clyde, Cromwell (and at times Ranfurly) to Dunstan Hospital. Both hospitals have access to a CT scanner and have generalists with skills in general medicine and rehabilitation. Both hospitals historically had similar admission volumes, however Lakes grew more from 2018-2019, partly due to its growing maternity unit. Lakes Hospital refers patients that need tertiary care to Southland Hospital, while Dunstan Hospital refers to Dunedin Hospital.
Outpatient care
Relationship between Queenstown and Southland Hospital
Invercargill/Southland is not growing as an area and its hospital use did not change significantly in 2018- 2020. Compared to Dunedin, outpatients clinics led by nursing and allied practitioners contribute a much larger proportion of outpatient attendances. Southland Hospital has fewer medical specialties than Dunedin and overall lower subspecialty numbers.
If there are an increasing number of services delivered at Lakes and Dunstan Hospitals then this may impact on the service volume and mix of Southland Hospital.
- Lakes Hospital has a limited number of subspecialties providing outpatient appointments.
- Lakes Hospital has the lowest outpatient use per capita in the Southern District for those in the Lakes catchment area. In contrast Dunstan hospital provides high outpatient activity - with 13 specialties offering a significant number of appointments per year (twice the average of the rural hospitals.) The reason for this difference is partly historical and partly relational – Dunstan made the conscious decision to invest in outpatients over other areas and has strong relationships with the Dunedin specialists, who frequently come across to the hospital.
- The low use of public services for those who live in Lakes catchment is thought to be due to a high proportion accessing private specialist care - 100 specialists operate in the Queenstown region. But it is not certain whether people from Queenstown utilise private because they can afford it (it is the most affluent area in Southern) or because they must, and do not want to travel to Invercargill. Lakes Hospital could leverage the subspecialty clinics provided at Dunstan hospital, being half the distance to Invercargill.
Relationship between Queenstown and Southland Hospital
Invercargill/Southland is not growing as an area and its hospital use did not change significantly in 2018- 2020. Compared to Dunedin, outpatients clinics led by nursing and allied practitioners contribute a much larger proportion of outpatient attendances. Southland Hospital has fewer medical specialties than Dunedin and overall lower subspecialty numbers.
If there are an increasing number of services delivered at Lakes and Dunstan Hospitals then this may impact on the service volume and mix of Southland Hospital.
A note on maternity services
Lakes District Hospital has a small birthing unit, but limited access to anaesthetics and obstetrics care so many travel over two hours from Queenstown to birth in Invercargill. In 2019 this was 230 births. The number of young families in Central Otago is growing, with Wanaka contributing the majority of the 122 births at Dunedin from Central Lakes in 2019, similar to the whole of Waitaki, Clutha and Central Otago (which ranged from 139-151). The map opposite displays "flight paths" for maternity services across the region. The thicker the line, the more events are indicated. |
FUTURE DIRECTION
A direction for how and when services develop in the Central Lakes needs to be agreed so that new or extended services are operational in time to meet the needs of the growing local population – and to provide a similar and consistent range of services and access to populations across Central Lakes. The decisions regarding the service mix and facilities required to service the future Central Lakes population, along with associated referral pathways to hub hospitals, will impact on future requirements for Dunedin and Invercargill.
Clinical leadership: The first step in a more integrated future for Central Lakes is to establish integrated clinical governance from across the two hospitals, primary care and community services for the area. There are some strong clinical leaders in the area and coordinated leadership is required to begin laying the building blocks for how an integrated system could work for Central Lakes and to lead the development of future service requirements. Building blocks: Clarity is required about the building blocks for an integrated service system that keeps up with demand, for example:
Clear pathway –develop a future strategic pathway in which all organisations in the system understand the broad strategic direction in terms of the development of local services, facilities and access to technologies. Define triggers for steps – once there is a clear direction, there is a need to define in advance the triggers for developmental steps, such as new facility development, based on detailed data and benchmarking, so that there is clarity about the points in which major change steps are required and these can be planned well in advance, rather that rushed and reactive. This approach will maintain safe clinical practice. There are varying opinions about the best pathway for services in Central Lakes. The decisions made lead to quite different futures and impact on the whole Southern system. A description of two potential options below illustrates the impact on wider systems: |
Proposed leadership for actions in this area: The rural hospital trusts should collectively prepare a future vision for the role and scope of rural hospitals.
The Southern DHB should set in motion analysis to inform the future pathway for Central Lakes.
Health NZ and the MHA will provide guidance around tertiary services.
The Southern DHB should set in motion analysis to inform the future pathway for Central Lakes.
Health NZ and the MHA will provide guidance around tertiary services.
Connected with community
Elements we are building from
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What we need to achieve
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The Health and Disability reforms aim to have hospital-based specialist services more connected to community services and for more people be proactively managed closer to home, only accessing specialist care when required.
Achieving this will require changes to relationships, systems of care and clinical cultures. Within the South, the need for a more connected specialist-community response has been highlighted by the new Dunedin Hospital.
The new Dunedin Hospital business case makes assumptions associated with reducing or holding demand and utilisation static into the future. These are presented in the table below.
Achieving this will require changes to relationships, systems of care and clinical cultures. Within the South, the need for a more connected specialist-community response has been highlighted by the new Dunedin Hospital.
The new Dunedin Hospital business case makes assumptions associated with reducing or holding demand and utilisation static into the future. These are presented in the table below.
Some of these assumptions relate to internal hospital systems and processes. But many of the assumptions will require connection with community-based system of care to better manage demand for and utilisation of hospital services. Much of this demand is driven by the health needs of older people. It is proposed that there is focused activity to develop an integrated specialist and community services plan for frail elderly. This process should be led by the project team that is managing the design and development of the new Dunedin Hospital internal systems of care – as it is a key element of future hospital viability. The integrated plan for frail elderly should be an exemplar to prototype new ways hospitals working with the community, that can then be applied across other specialist services. |
Elderly presentations to Dunedin hospital and LOS
- There are around 45,000 patients who present to Dunedin ED each year, which makes it a medium sized ED for New Zealand.
- 28% of these presentations are for elderly (65+), an increase of 1% per year in the last few years.
- Over one third of these were triage 4 or 5, which would indicate that a reasonable proportion (>4,000) were not acutely unwell.
- Although elderly have a higher admission rate, over half of all elderly have a Length Of Stay less than 2 nights, with 39% only 1 night.
- This is a significant number (23,000) who could be potentially managed more successfully managed closer to home and not require an overnight stay
*Note that ED refers to Emergency Department, and LOS refers to Length of Stay
The business case for the new Dunedin hospital requires that the shifts that need to occur are both at the lower acuity end of care, and for those that only need a short stay in hospital.
But further stratification of elderly is needed to determine is who otherwise “well” and who is frail. This is because the approach is different for the two groups. Well elderly can increasingly be managed in their own home or investigated and safely discharged earlier.
Frail elderly have a number of different drivers, consequences and solutions, which were explored by a working group of clinical leaders from across the system. This was established to explore data and the issues associated with how the system responds to the needs of the frail elderly. Members of the frailty workshop represented hospital, primary care, NGO, PHO and palliative care and were very experienced in end of life care.
Frail elderly are "Individuals over 65 years of age, dependent on others for activities of daily living, and often in institutional care. They may also show evidence of impaired mental function with a reduced mental test score."
Frail elderly
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Approaches to defining Frail Elderly and their end of life care:
One way of defining frail elderly was to look at the subset of elderly who were very old or clinically unwell. Of the 56,000 elderly in Southern, 6,700 of these were very likely to be frail purely by their age - being over 85 years. A further 20,000 are likely to be frail by using either a count of their Long Term Conditions, recognising that they have Polypharmacy, or both.
This approach therefore quantified the number of frail elderly in Southern, as around 27,000. Data was not available on how many of these elderly live in Residential Care, which may add to this number.
The utilisation of services at end of life showed that the majority of elderly do have a primary care appointment in the last year of life. However only one third do not have an unplanned admission (through ED) and 30% do not have a planned admission. Also 18% did not have an outpatient appointment.
Reassuringly the majority of elderly at their end of life continue to have contact with primary care and outpatients in the year before they die. While the hospital services are caring for the majority at some stage as an inpatient in that final year. Understanding the amount and timing of health resource use for frail elderly in the Southern region is the next stage in this analysis, as the trajectory is important to get quality of life immediately before death.
Frail Elderly Working Group
The working group described why the system was not fit for purpose for the frail elderly and the reasons for this. This is captured in the graphics below - drivers and consequences of the current system.
The working group described why the system was not fit for purpose for the frail elderly and the reasons for this. This is captured in the graphics below - drivers and consequences of the current system.
Acknowledging that the number of frail elderly is rising, the key thematic drivers of poor care of the elderly in the last years of life identified by the group were:
- That they struggle at home without many respite options, becoming increasingly isolated without the community networks required
- That the complexity of their overlapping conditions means that the time taken to care for them is increasing, which healthcare professionals do not have
- That those who live in Residential Care struggle if they also have co-existing cognitive impairment, as mental health in the elderly is not funded or prioritised
- That primary care is not integrated with the “support model”, so their true functional performance is not understood
- That their information does not travel with them to be easily accessible
The thematic consequences of poor care of the frail elderly in the last 1,000 days identified by the group are therefore:
- Limited access to Residential Care, struggling at home with a poor quality of life before death
- Difficulties obtaining an accurate patient history and supporting information leads to ambulance and primary care sending patients to emergency departments
- Little capacity for semi-acute planned care, leading to hospitalisation and delays in definitive treatment
- Secondary complications cause prolonged hospital stays with complications and deconditioning which leads to problems on discharge
There were six themes for improvements agreed on by the group, which relate to:
Discussion with geriatric specialists confirmed that a number of the themes or actions were evidence based on the literature on the frail elderly.
- The Simplification of NASC funding
- Integrating care plans
- The ceiling of care at end of life
- Proactive identification of frailty
- Integrating supportive care
- Deprescribing to decrease polypharmacy.
Discussion with geriatric specialists confirmed that a number of the themes or actions were evidence based on the literature on the frail elderly.
Following the identification of key themes for improvement, some areas for action and accountabilities were explored. It is proposed that this analysis is used to inform a second stage of work to develop a frail elderly system of care for the whole of the Southern Region. This work would involve:
Leadership: The Dunedin Hospital service design team should lead this work, with community partners, building from the work done to inform this strategic briefing. A stewardship group should be formed that will develop fraily elderly care pathways, oversee the implementation and monitor results. Stewardship groups should include the Iwi Māori Partnership Board, clinical governance and managerial representation from across the system including palliative care and NASC.
Action: The immediate focus should be on the definition and alert system for those that are frail elderly. This work could build from the initial analysis undertaken during the strategic briefing, with a plan of action being developed in a matter of months.
Resourcing: Implementation of an approach to frail elderly may require the streamlining of current resources to address regional issues, acknowledging that national resourcing is unlikely to change.
Data and feedback: There needs to be a system for monitoring progress using combined data extracted from various parts of the system of care to identify whether progress is being made on the drivers and/or consequences of poor care of the frail elderly, and ultimately differences in quality of life and mortality. Regular data should be made available to the Clinical Council.
Action: The immediate focus should be on the definition and alert system for those that are frail elderly. This work could build from the initial analysis undertaken during the strategic briefing, with a plan of action being developed in a matter of months.
Resourcing: Implementation of an approach to frail elderly may require the streamlining of current resources to address regional issues, acknowledging that national resourcing is unlikely to change.
Data and feedback: There needs to be a system for monitoring progress using combined data extracted from various parts of the system of care to identify whether progress is being made on the drivers and/or consequences of poor care of the frail elderly, and ultimately differences in quality of life and mortality. Regular data should be made available to the Clinical Council.
Enabling thriving generalism
Elements we are building from
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What we need to achieve
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Generalism has been described as “patient- and family-centred care; and as expertise in whole-person medicine. Generalism is not settings bound, and exists in both the hospital and community.”
Generalism can be practiced both in urban and rural settings. There has recently been progress in enhancing the role of generalists within the hub hospitals and this should continue.
For the purpose of this discussion the focus is on rural generalism.
The Southern District has the largest geography of all of the health boards in New Zealand, and it is estimated that over 40% of healthcare professionals in the region work rurally. There are ten towns with a population of more than 2,000, of which only half have a rural hospital and the remainder are cared for by a rural general practice. The staff at these facilities must have a generalist training and mindset.
Given the circumstance the Southern District should be positioning itself to be a national leader in designing a health system around capable rural generalism.
For generalism to flourish and contribute even greater value to rural populations, changes are required to the status of generalism within the system, training and development, models of funding and care, and clinical infrastructure.
Recognition in the system
Rural generalism should play a greater role in clinical leadership structures and be influential in the evolution of systems of care. The development of localities provides an excellent opportunity for generalists from across rural hospitals and primary care to develop locality integrated clinical leadership. This locality clinical leadership should be represented in district-level clinical leadership structures, so that rural generalism has a voice on health service development that is equal to that of specialist services. The whole system needs to better recognise the range of practice undertaken by rural generalists (across professions), and the levels of clinical risk that are often effectively managed in the community with limited access to supporting services and technologies. The system needs to recognise the positive impact that effective local services have on valuing patient’s time and providing care closer to home. We need to acknowledge that rural generalists often need to undertake rosters in unsocial hours to provide urgent response cover for their local population. |
Training experience and opportunities
Evidence suggests that clinicians who have had exposure to rural communities are more likely to practice in them in the future. This is a dose-response relationship, an increased number of placements increased the likelihood of someone returning to a rural community to nurse, be their physiotherapist or general practitioner.
Undergraduate: There are only a small number of medical, nursing and allied health students who get exposed to rural communities in the Southern District, and an even smaller number that get immersed for a full year of their training. The University of Otago and other training bodies have explored having a more structured approach to rural community placements and this should be encouraged
Post graduate: From 2022, doctors will be able to complete three months of their post graduate year 2 training in a community based setting, and rural hospitals will count as one of these. It is anticipated that this will give doctors more broad based clinical experience before choosing their career path, and exposure to the benefits of working rurally.
Extended Scope: The extension of scope for medical and nursing graduates means that those working rurally can provide an increasing amount of care onsite at the practice or rural hospital, without the need for referral. Training for extended scope occurs within a profession (e.g. nursing to become a nurse practitioner) but also between professions (how to practice effectively in non-urban settings). The Southern District should be encouraged to develop a more systematic approach to supporting extending the scope of generalists. This may require champions from within the generalist and specialist groups to lead the way. Oversight and training for extending scope does not necessarily need to be from Dunedin or Invercargill hospitals, Christchurch specialists have successfully provided oversight to West Coast for a long time and should also be engaged.
Evidence suggests that clinicians who have had exposure to rural communities are more likely to practice in them in the future. This is a dose-response relationship, an increased number of placements increased the likelihood of someone returning to a rural community to nurse, be their physiotherapist or general practitioner.
Undergraduate: There are only a small number of medical, nursing and allied health students who get exposed to rural communities in the Southern District, and an even smaller number that get immersed for a full year of their training. The University of Otago and other training bodies have explored having a more structured approach to rural community placements and this should be encouraged
Post graduate: From 2022, doctors will be able to complete three months of their post graduate year 2 training in a community based setting, and rural hospitals will count as one of these. It is anticipated that this will give doctors more broad based clinical experience before choosing their career path, and exposure to the benefits of working rurally.
Extended Scope: The extension of scope for medical and nursing graduates means that those working rurally can provide an increasing amount of care onsite at the practice or rural hospital, without the need for referral. Training for extended scope occurs within a profession (e.g. nursing to become a nurse practitioner) but also between professions (how to practice effectively in non-urban settings). The Southern District should be encouraged to develop a more systematic approach to supporting extending the scope of generalists. This may require champions from within the generalist and specialist groups to lead the way. Oversight and training for extending scope does not necessarily need to be from Dunedin or Invercargill hospitals, Christchurch specialists have successfully provided oversight to West Coast for a long time and should also be engaged.
Building trust and solutions
The health reforms provide an opportunity for rural clinicians to review and rethink current systems of care with the aim of providing advice on improvements.
Professions: Rural generalists are often the leaders in exploring new ways that professions work together. There are many examples of this innovation in the South already, working across historical silos, with good outcomes. With a future of increasing demand and predicted workforce shortages, generalists should take the lead in designing solutions that enables all clinicians to be working efficiently and at top of scope.
Primary care teams and rural hospitals: The way in which rural generalists within primary care and rural hospitals work together will be critical in achieving the aim of ‘care closer to home’. This strategic briefing encourages primary care and hospital generalists to embark together on a process of review of roles and services in their locality, and to together develop advice for Health NZ and the MHA on how better care could be commissioned in the future.
Tertiary providers: There needs to be a much more streamlined approach to communication between the generalists and the hospital. This is needed both in the acute and outpatient settings. When the decision has been made that a patient needs to be referred to a tertiary hospital, it is expected that all other avenues of care have been exhausted. Therefore when the generalist phones, the patient should be automatically accepted, so they can start the (often long) journey. It is very frustrating for the rural generalists when the hospital is not contactable, or the doctor is passed between specialties. Other regions have solved this problem with intermediary care navigators and/or triage at the front of the hospital and the tertiary hospitals should support a more streamlined referral system.
Specialists: Certain specialties lend themselves towards extended care, but almost all specialties can have more care be delivered remotely from interested, trained and supported rural generalists. Hospital-based specialists need to be open to innovation rurally and support it, and each new senior clinical employee to the hospital asked whether they would be happy to supervise an extended scope in their own areas of expertise. By identifying the supervisor in an area of rural need, and then reaching out to the rural community, the connection can be made. This model has successfully worked in other training and in colleges.
Models of care
Workforce teams and funding: Rural communities have had to organise their workforce differently to urban areas, given the variable mix of clinical professions, interest areas and training. One competency of the rural generalist, especially the general practitioner or rural hospital medicine doctor, is that they know how to devolve care to others who are skilled with patient groups. This means that the physiotherapist may be leading the care of cohorts of people with musculoskeletal conditions, the social worker those with complex health needs or nurse practitioners in chronic care, for example diabetes or heart failure.
This is important from a funding perspective, as historically the payments were fee for service and based on professions. It is time to explore the approach that care can be delivered by a range of healthcare professional, and that teams will self-organise into the right mix of leadership and the right amount of contact. Funding team-based care is crucial to distributing the workload and creating a sustainable service. Generalists and specialist co-operation: In a perfect environment, rural generalists work alongside visiting specialists, having prepared those patients who need specialist assessment or treatment for when they provide face to face clinics. With limited specialist appointments and infrequent overnight stays, the right patients need to attend the outpatient clinics and specialists’ time needs to be utilised on the wards when crucial to the care. West Coast DHB has demonstrated how this generalist and specialist relationship can flourish. The specialists enjoy travelling to Grey Hospital and surrounding areas, and often stay overnight. They provide a combination of operative care, outpatients and sometimes inpatient assessment with the rural generalist involved and then taking over care of these complex patients. Much of the remainder of care is provided via telehealth, and this tends to work for all parties. Telehealth: Rural Generalists have had to adopt telehealth to provide care for the geographical distances they cover and so are used to this channel. They also have learnt some of the tricks of making telehealth consults more effective, both those between clinician and patient, and clinician to clinician. Some of the specialists are concerned about the rise of telehealth, whether it be the impersonal nature, the inability to physically examine, the technology breaking down or cutting out, or the inefficiency from the hospitals perspective when a person does not answer. This new model of care is here to stay. It may be that rural generalists, who have more experience of telehealth, need to take the lead to support the hospital specialists to deliver accurate telehealth. Urgent care: One of the main services required by rural generalists is urgent and unplanned care. Compared to the urban setting, which often have a dedicated Urgent Care Clinic (UCC), the rural areas rely on the combination of doctors, nurses and paramedics through PRIME training. However the coordination of training and the planning of urgent care in rural South has been lacking. At a minimum, there should be a regular (quarterly) networking/training update for all providers of urgent/acute care, to be educated, network and share ideas on the provision of care. With increasing access to videoconferencing, this could be provided regionally or nationally. Other regions have created Urgent Care working groups (e.g. PAUA service level alliance in Auckland) at which the group members, explore data together, give updates and address common issues. Consistency in immediate care on the major high morbidity conditions (e.g. myocardial infarct, stroke, sepsis, significant head injury, major trauma) as well as treatment of the common urgent care conditions (e.g. cellulitis, DVT, pneumonia, renal colic, gastroenteritis, exacerbations of obstructive airways disease, pyelonephritis) will benefit all patients in the South. The treatments of these in the region should be agreed at a Clinical Governance level, acknowledged in the Health Pathways, and then funded accordingly so that the best outcomes occur. Clinicians should not obstructed by cost when dealing with these common and life threatening conditions. POAC: Primary Options for Acute Care has been well utilised throughout New Zealand as a funding stream to be used to keep patients out of hospital. 85-90% of patients are successfully treated in the community in Wellington, Christchurch and Auckland. While each has varying clinical thresholds for funding, they all acknowledge that there is often no pathway to do “the right thing” and so allow clinicians to order tests or perform management in the assumption that if reasonable will be claimable. The South should invest in POAC, learning from the experience of the other regions. It should make it consistent throughout the whole area, and recognise the impact of a rural hospital admission and weight the funding accordingly. This impact is not only the cost of a bed night in a hospital, but also the time (and financial) cost to the patient and their whānau. |
Infrastructure - Minimum requirements
Investigations: There should be a minimum specification for investigations which can be done in any rural area and without a charge to the patient. This would include laboratory tests and radiology. This is provided by the rural hospitals in the larger settings, but there are only five of these in the whole of the South. This means that there are limited access to core care functions, especially in the larger towns (2,000-3,000) people of Te Anau, Wanaka and Lake Hawea. These three town have to charge co-pays for blood tests and X-rays, with the latter sometimes being done by the nurse as there is no MRT available. With the closest rural hospital an hour or more away, some patients are being let down in their access to core care.
Interventions: Similar to investigation, some patients need definitive treatment for their condition which involved a specific intervention. The example of hemochromatosis is given, where a patient needs regular venesection (blood letting). However although the general practices can do this to improve the patients health, there is no consistent funding for rural generalists to provide this intervention. In urban settings there are contracts for this type of service, but these organisations seldom work rurally. The Southern healthcare system should acknowledge the bespoke or specific definitive interventions that may be required and have a mechanism to fund these.
Proposed leadership for action in this area: Rural hospital network in collaboration with Iwi Governance and HNZ.