Models of Access and Clinical Service Delivery for People with

HIV in Australia project

AFAO Positive Services ForumJune 2009

The problem (1)• Client group is changing– increasing in number with continuing new cases and

increased life expectancy and therefore ageing

• Clinical response is changing– increased complexity– increased ambulatory component of care– changed population with different needs and clinical

course– HIV as a chronic condition– Co-morbidities

• Social and psychological health effects

The problem (2)• Workforce is changing– ageing, recruitment, retention, replacement & training,

practices – General health workforce– HIV specific workforce

• Health systems– Tailored to acute and hospital based problems– System changes (PHC strategy, PHT, National HIV Strategy,

Chronic Disease Strategy etc)– State, Territory, Commonwealth

• Global financial crisis• Data, assumptions and projections.

Response

• Overseen by BBVSS and Commonwealth Ministerial Advisory Committee

• Advisory Panel• Steering committee• Project officers• Funded from late July 2008

Problem analysis• NAPWA and ARCSHS• Models of access to and clinical service

delivery for:– HIV in Australia– HIV internationally– Chronic disease

• Service mapping– Health services and HIV services in Australia

• Workforce issues

Problem analysis

• Methods– Literature reviews– Questionnaires and interviews: phone, email,

face-to-face– Requests for data

• Issues– completeness, currency, evidence base,

generalisability

HIV populations in Australia – implications for service access and delivery

• Increasing, ageing, treatment and co-morbidity issues

• Geographic trends• Mental health• Stage of HIV treatment and service needs– Location– Pharmaceuticals– Other services

• Key sub-populations (relates to above point)

ARCSHS concludes• Two important emerging issues:– potential changes in the patterns of geographic location of

the HIV-positive population– changes in how and what type/style of services are

needed, wanted or accessed

• Key issue remains tailoring medical and other service delivery to individuals– requires a balance between mainstream and HIV-specific

services in particular areas

Themes and Chronic Disease (1)• Policy and funding support and change• Patient (and carer) centred• Spectrum of responses from prevention to

end-of-life• Key role of community

Themes and Chronic Disease (2)• Health systems– multidisciplinary, integrated, coordinated, flexible,

planned, evidence based and supported• Clinical information systems: – evidence based guidelines, health plans, recall,

reminder and follow-up systems• Delivery systems– self management, shared care, nurse practitioners,

supported or comprehensive care, referral pathways and access to primary and specialist and multidisciplinary health care, hospitalisation, rehabilitation, palliation and end-of-life

– Workforce – recruitment, retention and training

Recurrent themes (HIV and Oz)

• Service access: geographical and cultural• Service delivery: re-oriented, integrated,

coordinated, patient centred, multi-disciplinary• Planning – strategic, coordinated, consultative• Information management and communication

technology• Workforce – GP, development• Evaluation and research

Themes and International (access)• Service models – multi-disciplinary, dedicated

case managers• Application of health information systems• Physical access– Location, geographical proximity, out of hours,

access to appointments short waiting room time

• Free services and ART• Perceived quality of care and service

availability

Themes and International (service delivery)• High patient caseloads• Services conducting clinical trials• Case management

All associated with improved clinical outcomes, HAART use and continuity of care

Themes and International models• Patient centred care and continuum of care• Chronic care models:– self management, case management, integrated

multidisciplinary teams, – coordinated delivery systems– effective health information systems

• Response to co-morbidities (mental health, D&A)• Response to non-clinical health determinants such as housing,

employment• Insufficient evidence: need for evaluation and research

HIV services in Australia

What is done, where and by whom?• GPs and s100 prescribers• Sexual health clinics• Secondary and tertiary services• Aboriginal health services

Mix is different in different parts of the country (state, town, suburb)

Models within models• Self management• Case coordination (supported to comprehensive to

intensive management)• Shared care• Other support/management services: multidisciplinary• Supporting non-HIV specialist (eg managing dementia and

stroke)• Remote (primarily) services:

• Specialist advice and mentoring• Telemedicine• Phone links• Fly in; fly out• Patient evacuation

Themes and Workforce (1)• Generally: undersupply, ageing population,

increasing part-time work, trend to specialisation for doctors and nurses, silos for practice and training, problem of too few training places

• Barriers to recruitment, retention and training in HIV sector

• Barriers to enhanced primary health care (eg mental health, ageing, D&A, case management, multidisciplinary teams)

Themes and Workforce (2)Strategies• Financial and “lifestyle” incentives• System change and support for change– Enhanced PHC, multidisciplinary, shared care– Mentoring

• Other areas– Rural and remote– Indigenous, CALD: patient journey issues

• Training

Themes and Workforce (3)

Mostly untested• Need effective and sustainable interventions• Good data and continuing evaluation and

research

Demo project 1: Shared Care

• To explore mechanisms for facilitating and delivering shared care in the community

• To determine the features of community provided shared care & who is referred for this level of care:– Level of patient need– Level of practitioner training and where delivered– Role & frequency of specialist review– Other contributors (nursing, practice nursing, CBO)

• To determine and develop a range of community provider supports

Demo project 2: High caseload s100 prescribers

• To develop and implement a series of tailored supportive solutions to support individual high caseload community practices

• To evaluate outcomes related to provider recruitment and retention

Demo project 3:Nurse based initiatives

• To explore, implement and evaluate a range of nurse based strategies aimed at increasing access to clinical service delivery

• These may include:– Practice nursing– Nurse practitioners– Community based nurse models

Other priorities (X 5)• To implementation and evaluate – strategies aimed at increasing the linkage between

laboratory and clinical settings– innovative strategies for linking with patients and with

doctors at time of diagnosis

• To support, implement and evaluate– e-health strategies– communication between services– self management strategies and exploring these in tandem

with above priorities

Supporting & enabling recommendations

• Additionally, enabling and supporting priorities that emerge from the National HIV Strategy

• Fundamentally– The support of routine and longitudinal data sets

such as ARCSHS– The expansion of the AHOD data set– Continuation of the joint BBVSS/ MACASHH

committee overseeing this project to act as implementation oversight group

Conclusion• Comprehensive piece of work which provides a

solid evidence based platform for further work• Responded to many issues and raised many

more questions• Need for further work (as demo projects

highlight)• Need for strategic action given demands

arising from current health, social and international change and pressure