Northern Respiratory Partnership Project · Box 4.4 Asthma SA Case Study: NRP school and...

Northern Respiratory Partnership Final Project Report – May 2013 to May 2015

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Northern Adelaide Medicare Local

Northern Respiratory

Partnership Project

______________________________________________________________

Final Report & Evaluation

May 2015


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This publication is created by the Northern Adelaide Medicare Local (NAML) Ltd. in collaboration with:

The Northern Region GP Council

The Northern Adelaide Medicare Local gratefully acknowledges the financial and other support from the Australian

National Preventive Health Agency in funding this project.

Enquiries

P.O. Box 421, Elizabeth SA 5112

2 Peachey Road, Edinburgh North SA 5113

(08) 8209 0700

[email protected]

www.naml.com.au

Copyright

All content in this publication is copyrighted by the Northern Adelaide Medicare Local (©2015) unless otherwise stated or

it may rest with the contributor of the content. The Northern Adelaide Medicare Local undertakes reasonable care to

ensure all information is correct at time of publishing. Unauthorised use and duplication of the document (or parts thereof)

is unlawful and strictly prohibited. Valid permission can be obtained through contacting the publisher using information

provided above.

Northern Adelaide Local Health Network Drug and Alcohol Services SA

Asthma Foundation SA Lung Foundation Australia

Pharmaceutical Society of Australia (SA/NT Branch) Cancer Council SA – Quitline


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TABLE OF CONTENTS

Page number

Executive summary 6

1 Introduction 9

2 Methodology 15

3 Respiratory hospital admissions and emergency department attendances 21

4 Objective 1 Primary prevention 33

5 Objective 2 Secondary prevention 55

6 Objective 3 Tertiary prevention 76

7 Objective 4 Comprehensive approach 82

8 Discussion and conclusions 92

Appendices Appendix 1 Northern Respiratory Partnership partner organisations and

expected contribution Appendix 2 NRP project plan March 2014 (revised from April 2013) Appendix 3 Information sheet to general practices on NRP opportunities Appendix 4 Asthma Assist referral form Appendix 5 Hospital Working Group on NALHN responses to asthma and

COPD Appendix 6 Issues addressed by the NRP Hospital Working Group – a

summary Appendix 7 Maps showing COPD prevalence and pulmonary rehabilitation

services Appendix 8 Evaluation questions for NRP partners Appendix 9 Summary of achievements against NRP process and outcome

indicators

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References


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LISTS OF FIGURES, BOXES, TABLES AND MAPS

Figure 2.1 Prevention across the continuum of care

Figure 2.2 Northern Respiratory Partnership Program Logic

Figure 3.1 Emergency department presentations, by SLAs, in the NAML region, 2010-2015

Figure 3.2 Triage categories 4 and 5 emergency department presentations, 2012 and 2015

Figure 3.3 Hospital admissions, by SLAs, in the NAML region, 2010-2015

Figure 3.4 Data for inpatient length of stay for both conditions combined

Figure 4.1 Fact sheet on reducing smoking for Aboriginal and Torres Strait Islander People

Figure 4.2 Workplace staff confidence post asthma first aid training

Box 1.1 Why Chronic Obstructive Pulmonary Disease (COPD) and asthma?

Box 2.1 Summary of the NRP project goal and objectives

Box 3.1 A note on the data

Box 3.2 Choosing priority locations for NRP interventions

Box 4.1 A note on the smoking data

Box 4.2 What else will the NALHN progress to support consumers and staff to quit smoking

and to prevent uptake?

Box 4.3 ‘Breathless in the North’

Box 4.4 Asthma SA Case Study: NRP school and children’s service initiative

Box 5.1 Pharmacies have a key role in respiratory health

Box 5.2 Case Study: Asthma Pharmacy Referral Pathway (APRP) program

Box 5.3 Survey of pharmacies participating in the NRP

Box 5.4 Case study: A focus on COPD screening, diagnosis and management in general

practice

Box 5.5 Results of the Australian Primary Care Collaboratives Quality Improvement

Partnership project on COPD

Box 5.6 Australian Lung Foundation COPD online training

Box 6.1 Hospital Working Group reflections on the NRP

Box 7.1 NRP partners’ reflections on the project

Table 3.1 Admissions and ED attendance data for asthma and COPD at project baseline

compared to final year of project

Table 3.2 Emergency department use by hospital 2012 and 2015

Table 3.3 Emergency department use by age 2012 and 2015

Table 3.4 Triage category - 2012 to 2015

Table 3.5 Emergency presentations by age total 2012, 2013, 2014, 2015 (3 months) combined

Table 3.6 ED presentations by diagnosis (broad group) by year by after-hours status

Table 3.7 NRP priority SLAs by diagnosis

Table 3.8 Admissions for asthma, COPD and bronchiectasis / acute bronchitis 2012 and 2015

Table 3.9 Admissions by hospital 2012 and 2015

Table 3.10 Admissions by age 2012 and 2015

Table 3.11 Contribution of three priority areas to admissions and ED attendances for asthma

and COPD

Table 4.1 Smoking prevalence for those aged 15 years and over living in the NAML region,

2012 to 2014 from the Health Omnibus Survey

Table 4.2 Awareness of options that would help people to quit smoking

Table 4.3 Source of referral for NAML residents contacted by the Quitline, 2013 and 2015

Table 4.4 Education sites in the priority areas in the NAML region with current asthma first aid

training across the intervention period (May 2013-Dec 2014)


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Table 4.5 Evaluation of participant knowledge and confidence following asthma first aid training

Table 5.1 Number of general practices and pharmacies in the NAML region and priority

locations

Table 5.2 Pharmacy continuing professional development credits assigned for the asthma

initiative

Table 5.3 Training undertaken through the NRP

Table 5.4 Coverage of key issues through the NRP

Table 7.1 VicHealth Partnerships Analysis Tool results

Table 7.2 Areas of involvement of major NRP partners

Table 8.1 NRP budget expenditure

Map 1.1 The Northern Adelaide Medicare Local region

Abbreviations AHCSA Aboriginal Health Council of South Australia Inc.

ABS Australian Bureau of Statistics

AHWs Aboriginal Health Workers

AIHW Australian Institute of Health and Welfare

ANPHA Australian National Preventive Health Agency

APCC Australian Primary Care Collaboratives

ATSI Aboriginal and Torres Strait Islander

CALD Culturally and linguistically diverse (communities)

CPD Continuing Professional Development (credits or points)

CTG Closing the Gap

COPD Chronic Obstructive Pulmonary Disease

DASSA Drug and Alcohol Services South Australia

ED Emergency department

GP General Practitioner

GPMP General Practice Management Plans

LFA Lung Foundation Australia

LMH Lyell McEwin Hospital

NALHN Northern Adelaide Local Health Network

NAML Northern Adelaide Medicare Local

NGOs Non-government organisations

NLRC Nurse-Led Respiratory Clinic

NNT Number Needed to Treat

NRGPC Northern Region GP Council

NRP Northern Respiratory Partnership (project)

NRT Nicotine replacement therapy

PHIDU Public Health Information Development Unit

PMC Project Management Committee

PR Pulmonary Rehabilitation

PSA Pharmaceutical Society of Australia (SA/NT Branch)

RACFs Residential Aged Care Facilities

SA South Australia

SAHMRI South Australian Health and Medical Research Institute

SES Socio-economic status

SLA Statistical local area


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EXECUTIVE SUMMARY

The Northern Respiratory Partnership (NRP) project was designed to improve respiratory health for

people living in the northern Adelaide region through the implementation of a comprehensive and

coordinated approach. The NRP was one of seven Australian Government funded projects

designed to support integration of prevention and primary care approaches through Medicare

Locals.

Chronic respiratory conditions affect many Australians. Until recently respiratory health has not

received as much attention as other chronic conditions yet around one in ten people have asthma

and 7.5% of people over 40 years have Chronic Obstructive Pulmonary Disease (COPD). These

two conditions impose a significant burden on the individuals affected and their families and carers.

Smoking is a major contributor to COPD and can make asthma management more difficult.

Hospital admissions for both asthma and COPD are considered potentially preventable. For people

living in the northern Adelaide region there were 2076 hospital admissions and 2798 emergency

department attendances related to asthma, COPD and related conditions in the 12 months to March

2015.

The Northern Adelaide Medicare Local was the NRP lead agency working in close collaboration

with seven major partners:

Northern Adelaide Local Health Network (NALHN)

Drug and Alcohol Services South Australia (DASSA)

Asthma Foundation SA (Asthma SA)

Lung Foundation Australia

Pharmaceutical Society of Australia (SA/NT Branch) (PSA)

Cancer Council SA – Quitline

Northern Region GP Council (NRGPC).

The project aim was to implement an integrated approach to prevention across the health care

continuum through the region’s population health programs, primary health care services and acute

care. Chapter two sets out the underpinning project logic of the project plan that involved action

across four key objectives:

1. Primary prevention – minimising the risk of respiratory conditions in the population as a whole,

as well as with groups at risk, and creating healthier policies, environments and practices

2. Secondary prevention – ensuring the early identification and best practice respiratory health

management in primary care services

3. Tertiary prevention – ensuring those with existing conditions are supported to stay well and

reducing the risk of exacerbations, and further deterioration of health and wellbeing

4. A coordinated and collaborative whole-of-community approach to the prevention of COPD,

asthma and smoking.

As a chronic disease area with previously little concentrated focus, it was difficult to determine an

overall project goal that would demonstrate outcomes well. It was in this context that an aspirational

goal to reduce avoidable hospital admissions and emergency department attendances by 10% for

COPD and asthma in the Northern Adelaide Medicare Local region over two years was set. In the


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end, the project timeframes meant that in practice there was less than a full 24 months of

intervention. This, plus factors including high levels of community disadvantage, changes at the

hospital level and investment of time to primary prevention with longer timeframes, means the target

was not achieved, though there were small improvements.

Chapter three sets out data on admissions and emergency department attendances for people

living in the NAML region and shows areas with disproportionately high rates of both. The statistical

local areas of Playford Elizabeth, Playford West Central and Salisbury Central were the priority sites

where additional attention was focussed within the NRP.

Chapters four to seven report in detail on the work undertaken against each of the objectives as well

as presenting the results. Lessons learned are included for each section along with

recommendations going forward.

The project outcomes include:

A reduction in smoking prevalence in the NAML region – the NRP project had a major focus on

smoking prevention/cessation activities and this would have contributed to this achievement

Provision of various ‘enablers’ for quit smoking support including training, electronic referral

systems, distribution of resources, multiple partnerships and plans. The Local Health Network

has committed to further action to assist patients to quit. This has provided a good base for

further action.

Increased capacity of schools to respond to children with asthma, through asthma first aid

training for school staff. Training was provided to 93 education settings (schools and children’s

services) reaching 43 out of 58 schools in priority areas and achieving a 23% increase in the

number of schools trained in non-priority areas (79 additional services trained out of 288).

Practice improvements for the eight pharmacies and nine general practices (the majority of

which were in the priority locations) that received intensive support.

Conduct of at least 429 COPD screenings in general practices in the region.

Referral of 165 people from eight pharmacies to the Asthma Assist infoline, with 113

successfully contacted by Asthma SA. Evaluation at 12-months post-intervention (n=48)

showed:

o Asthma Control Scores increased from 15.47 at baseline to 21.24

o 69% had an Asthma Action Plan (22% at baseline)

o 79% were using a spacer (35% at baseline)

o 85% had a review by a general practitioner (54% at baseline)

o there were fewer hospital admissions over that 12-month period compared to the 12

months preceding baseline.

Training reaching nearly 200 primary health care providers (general practitioners, practice

nurses and pharmacists) with 13 sessions held over the two years.

In the priority areas 36.3% of pharmacies and 34.5% of general practices were engaged in one

or more NRP activities, approaching the 40% target.

Improvements in hospital systems including policies, referral protocols and collaboration on

issues such as pulmonary rehabilitation.

Chapter 7 reports on the collaborative and coordinated approach adopted by the NRP. Testing the

partnership model was fundamental to the NRP and the formal partners were overwhelmingly

positive about the partnership and the success of the collaboration. They believe the NRP allowed

strategies to be implemented that would not have been possible in isolation and there is strong

support for future partnerships.

The final chapter summarises the NRP work and points to the lessons learned overall as well as

indicating future directions. It is anticipated there will continue to be a focus on respiratory health in


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the northern region of Adelaide through the Adelaide Primary Health Network and there is potential

for integration of the related respiratory work of other metropolitan Medicare Locals. This evaluation

informs the shape and focus of such a project that can build on the current project, be innovative

and health outcome focused as well as expandable/transferable into other regions and beyond.

Suggested next steps include:

Consolidate and expand the NRP approach across metropolitan Adelaide – build on what

worked well and continue to focus more intensive interventions in priority areas. Continue to

capture data in the priority areas in northern Adelaide, and across a wider region, to show what

can be achieved in asthma and COPD prevention/management through partnerships.

Given the NRP experience of what is feasible, identify the central action areas for sustained

effort where the largest shift in outcomes can be achieved.

Maintain a focus on reducing hospital admissions and emergency department attendances as

drivers for the project but set project goals based around the secondary advantages that are

now known to be gained by a partnership focus on chronic disease prevention/management.

Invite project participants to hear the results of this project and encourage participation in

achieving future goals in collaboration with primary and acute care. Ask for further ideas on how

to achieve changes.

Continue to support improvements in general practice client information systems to enable

measures of effectiveness at the practice level.

Continue the focus on inequities and target providers and consumers living in the high need

areas.

Maintain a Project Management Committee and engage key partners and stakeholders.

Tackle mental health and smoking in a concerted way – bring on new partners to assist and use

the NRP expertise in partnerships to build momentum. Apply consistent messages across the

continuum of care. Build on the connections made and become a leader in this area.

Have a focus on COPD exacerbation management with general practice and the hospitals. This

includes the stepping up and down of medications and referrals back to GPs from hospital.

Explore potential for new services, including Lungs in Action and pulmonary rehabilitation

programs in the community with support from Lung Foundation Australia.

Focus on children and asthma – explore innovative ways to reach children in the area through a

NALHN / Asthma SA partnership, with support from the Northern Health Network.

A summary of achievements against the project plan is provided as an appendix.


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CHAPTER 1 INTRODUCTION

The Northern Respiratory Partnership (NRP) project aimed to implement an integrated approach to

prevention across the health care continuum through the region’s acute care, primary health care

services and population health programs. The focus was on reducing the impact of unmanaged

asthma and Chronic Obstructive Pulmonary Disease (COPD) and associated risk factors, including

smoking.

The project set an aspirational goal to reduce avoidable hospital admissions and emergency

department attendances by 10% for COPD and asthma in the Northern Adelaide Medicare Local

(NAML) region over two years (May 2013 to May 2015).

NAML was responsible for coordinating and driving implementation of the project, in partnership

with the project partners:

Northern Adelaide Local Health Network (NALHN)

Drug and Alcohol Services South Australia (DASSA)

Asthma Foundation SA (Asthma SA)


Pharmaceutical Society of Australia (SA/NT Branch) (PSA)

Cancer Council SA – Quitline

Northern Region GP Council (NRGPC).

Map 1.1 shows the region covered by NAML:

Map1. The Northern Adelaide Medicare Local Region


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RESPIRATORY HEALTH

Lung health is essential to living well yet many Australians suffer from asthma or COPD and the

northern Adelaide area is no exception. Both conditions impact on quality of life of individuals, their

families and carers and contribute to potentially preventable hospital admissions that are stressful

for patients and their families and expensive for the health system.

COPD is mainly caused by smoking, and is therefore largely preventable. Asthma is not caused by

smoking but smoking, or exposure to secondhand smoke, can contribute to asthma flare-ups. Both

prevention and good primary care based management can help avoid hospitalisations and

emergency department attendances. Box 1.1 provides more information on both conditions.

Box 1.1 Why a focus on Chronic Obstructive Pulmonary Disease (COPD) and asthma?

COPD is a progressive life-limiting disease of the lungs that causes shortness of breath. COPD cannot be cured or reversed, but it can be treated and managed. COPD is an umbrella term that includes emphysema, chronic bronchitis and chronic asthma that is not fully reversible.1

Lung Foundation Australia report that:

14.5% or one in seven Australians 40 years or over have airflow limitation of their lungs. This figure increases to 29.2% in Australians 75 years or over;

7.5% of Australians 40 years or over have COPD that has progressed sufficiently to where symptoms may already be present and affecting daily life. Half of these people will not know they have it. 2

Under-diagnosis of COPD is also common.3

About 70% of COPD in men is attributable to smoking and 60% for women.4 Exposure to irritants like dust and fumes can also increase the risk of developing COPD.5 The disease is progressive but treatment can slow the progression of the disease and help with symptom management. Despite the evidence for its effectiveness there is limited use of, and access to, pulmonary rehabilitation (PR).

The NAML region sits in the mid-range for self-reported COPD age adjusted rates (2.4 per 100) but several Statistical Local Areas (SLAs) have much higher rates (3.1 and 3.2). Deaths from COPD 0-74 years (2008-12) show 9.2 per 100,000, higher than the Australian capital cities rate of 6.5, with one location in the NAML region having one of the worst rates in Australia.6

Asthma is a chronic inflammatory condition of the airways associated with episodes of wheezing, breathlessness, persistent cough and chest tightness. It affects people of all ages and has a substantial impact on the community. Like COPD, there is no cure for asthma. Asthma rates in Australia are high by international comparison but it is not clear why. Around one in ten people have asthma in Australia and prevalence rates in children have been declining over the last 12 years.7

There were 394 deaths due to asthma in Australia in 2012.8

Poor asthma control (frequent symptoms and exacerbations) is a common problem. It is estimated that 90% of people are not using their medications and devices appropriately9 and there is an overuse of reliever medications. Aboriginal and Torres Strait Islander peoplei have higher death rates and hospitalisations from asthma.10

i For brevity, the term ‘Aboriginal’ will generally be used throughout this report as the majority of Indigenous Australians

living in the northern Adelaide region are of Aboriginal rather than Torres Strait Islander descent.


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Self-reported asthma prevalence is 10.6 for the NAML region, slightly higher than the Adelaide rate of 10.3 with some higher areas.

Both asthma and COPD admissions are considered potentially preventable. Overnight admissions for respiratory conditions data ranks NAML 12th of all Medicare Locals across Australia.11 COPD is the second leading cause of avoidable hospital admissions in Australia, with one in ten hospital admissions attributed to the condition.12 Around 19% of general practice encounters are for respiratory problems. Comprehensive disease management plans are recommended for both conditions and can help minimise hospitalisations but only 20% of people over 15 years of age with asthma have an action plan13 and rates are also low for COPD.

Both conditions contribute to financial costs including loss of workplace productivity and absenteeism from education settings and workplaces. The cost of medications imposes a cost on society as well as the individual and family.

Asthma and COPD are more common in Indigenous Australians with five times the death rate for COPD.14 The prevalence of both conditions increases with socio-economic disadvantage.

People with asthma smoke at least as much as people without asthma despite the known side-effects and an estimated 7.8% of children with asthma live where there is smoking inside the home.15

At project baseline, smoking prevalence rates in the NAML region were higher than the Australian average.

Demographic data also shows the NAML population to have high levels of disadvantage (e.g. high proportion of single parents, unemployed, lower median incomes). Aboriginal people comprise 1.7% of the South Australian population overall but around 40% of the state’s Aboriginal people live in the NAML catchment area with higher density in certain locations. These social determinants of health have an impact on the prevalence of asthma, COPD and risk factors, as well as influencing self-management efficacy.

PREVENTION IN THE MEDICARE LOCALS – PROJECT FUNDING

The NRP was one of seven projects funded by the (former) Australian National Preventive Health

Agency (ANPHA) under the Disease Prevention and Health Promotion in Medicare Locals Program.

The program sought to build an evidence-based sustainable approach to disease prevention and

risk factor reduction that is integrated with primary health care, to help manage the emerging

challenges for the health system of an ageing population and an increasing burden of chronic

disease.

The Program set out to build upon the Medicare Locals’ role to be responsive to their communities’

health needs and reduce service fragmentation by improving overarching coordination between

services and programs in their local regions. It targeted innovative interventions and approaches

that:

are most likely to achieve measurable outcomes

promote local partnerships

integrate local activities with national and State/Territory-based programs and initiatives to

maximise reach and reduce inefficiency and duplication

seek to reduce health differentials by addressing need and targeting high risk population groups;

and


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contribute to the wider dissemination of program learnings and capability development across the

Medicare Local network.

The NRP project commenced in May 2013 and ran to the end of May 2015. NAML received funding

of $434,520 plus GST from ANPHA.

THE NORTHERN RESPIRATORY PARTNERSHIP APPROACH

The NRP project was designed to address COPD, asthma and the major risk factor, smoking, using

good practices approaches.16 The underpinnings of the approach were:

Implementing prevention across the continuum of care including primary, secondary and tertiary

prevention

Recognising the social determinants of health and their impact on health inequities and testing

the practicality of consciously applying a progressive universalism approach, providing universal

programs and service responses to the whole community and enhancing responses for those

with greater levels of social disadvantage, who have poorer health, more risk factors and use

fewer preventive health services17

Applying a comprehensive focus on respiratory health at sufficient intensity to make a difference

for an initial two-year period and be able to assess if it warranted ongoing commitment

Increasing the early diagnosis and best practice treatment of COPD and asthma, and improving

the smoking cessation supports provided by primary health care services. The NRP wanted to

build understanding of the impact of supporting better primary care with a focus on those

localities where significant numbers present for avoidable admissions to hospitals

Working towards enhanced integration of activities. Multiple strategies are critical but it is

important to minimise duplication and disconnected strategies

Developing partnerships to support a sustainable long-term approach – this included

partnerships within SA Health, with other sectors, non-government organisations (NGOs) and

the community, bringing together organisations who do not necessarily have a history of

collaboration

Building leadership and workforce capacity as enablers for good practice

Evaluating the program to build the evidence and setting measurable reductions in COPD- and

asthma-related admissions and emergency department (ED) attendances

Taking a life course approach – addressing risks that accumulate from pregnancy throughout life

and increasing protective factors.

These are explored further throughout the report.

NRP PARTNERS

Northern Adelaide Medicare Local was the lead agency responsible for coordinating and driving

implementation of the project in collaboration with six partner organisations. The organisations and

their expected contribution to the NRP were specified in the project application and are outlined in

Appendix 1. In summary, organisations were engaged because of their content and technical

expertise; links with consumers and professional groups; role in providing services, programs and

resources both in primary health care, acute care and the community; influence on policy directions;

and mutual interest in achieving NRP project outcomes.

Chapter 7 provides more information on each of the project partners.


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CONTEXT FOR THE NRP

The NRP project took place at a time of considerable change in the health sector. This provided the

following challenges to the project:

The project was funded by ANPHA and included the provision of regular project and evaluation

advice, as well as the preparation of common evaluation tools for all seven funded Medicare

Local projects. ANPHA was de-funded in the middle of 2014, ending this support and

collaboration

NALHN was a foundation partner but had not yet established their dedicated respiratory unit

SA-based funding for tobacco control social marketing was significantly reduced in 2014 and

programs, including a smoking and pregnancy project, were stopped in late 2013. Funding for

Quitline programs, including those with the non-government sector, was also cut. This reduced

the high visibility of ‘quit smoking’ information and messaging and the practical ‘on the ground’

programs with which the NRP could partner, such as smoking and mental health

Other prevention programs in SA had significant state and federal government funding

reductions during the course of the project meaning less prevention capacity in the region

The Australian Medicare Local Alliance closed in June 2014, reducing the level of support to

Medicare Locals

There were also state and federal elections, proposed changes to general practice funding and

the renegotiation of the community pharmacy agreement during the course of the project.

All this created a less than supportive context for the work of the NRP.

ABOUT THIS REPORT

This report is both a report on the activities of the NRP and an evaluation report. As a project report

it provides extensive detail on the project activities undertaken, resources developed, data collected

and includes case studies on key initiatives. This may be useful to inform future partnership,

prevention and/or respiratory projects undertaken.

As an evaluation report it reports on outcomes as well as the lessons learned. The NRP prepared a

detailed project plan with multiple performance indicators and outcome measures identified, along

with data sources and timeframes for implementation. This forms the mainstay of the evaluation. In

addition, the interviews with each project partner were undertaken and specific project components

evaluated in more detail.

The project funding was designed to contribute to the wider dissemination of program learnings and

the NRP Project Management Committee (PMC) supported the sharing of details of the project as

part of a ‘legacy’ document as well as including suggested directions for the future. It is the intention

of the new Adelaide Primary Health Network to progress work on respiratory health so throughout

the report there are suggestions for future action under the heading ‘Proposed Way Forward’.

These apply to the northern Adelaide region in particular but most will have relevance more broadly.

There is a challenge in reporting on projects such as the NRP. The scope of this project, from the

overall goal to the breadth of activities and indicators, was ambitious but consistent with best

practice evidence around the need for comprehensive approaches across the continuum of care in

order to achieve the intensity of action to make a difference and avoid ‘weak prevention’.

This report takes the view that sharing the knowledge of what was and was not achieved, and why,

is important to build the evidence base around practical implementation of prevention activities.

Positive achievements, both planned and opportunistic, are highlighted as well as covering those

areas where there were limited or no outcomes in the two years of operation.


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The NRP was evaluated by the project advisor, not an independent evaluator. The project advisor

has been significantly involved in the project throughout. The risk of bias is mitigated by the detailed

evaluation criteria and review by the PMC. Data has been analysed by NAML staff who are

independent of the project.


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CHAPTER 2 METHODOLOGY

This chapter provides information on what the NRP aimed to achieve, the rationale for the

methodology used and the project logic, as well as information about the project plan.

The NRP project was formulated by NAML in response to the ANPHA call for grant applications

(see chapter 1). The project application included a detailed description of the methodology to be

employed in the project and included a project plan informed by state and regional health reform

directions, literature and health needs. All partners had some level of input into the project

application and signed letters of support. Their in-kind contribution was costed and formed part of

the application. The initial plan was approved by ANPHA in May 2013 with a revised version

approved in April 2014.

PROJECT OUTLINE

The overall goal – to reduce avoidable hospital admissions and emergency department attendances

by 10% for COPD and asthma in the Northern Adelaide Medicare Local region by 31 March 2015 –

was set in the beginning.

Four key objectives were identified (see Box 2.1) and each had a series of sub-objectives with

specific actions and a range of indicators both performance- and outcome-based. The overall

framework was based on implementing prevention across the continuum of care, i.e.:

primary prevention addressing risk factors, especially smoking and risk conditions and raising

awareness about respiratory health with the whole population and groups at risk

secondary prevention involving more integrated, comprehensive and timely approaches to the

early identification, case-finding, risk assessment and better management of those with multiple

risks

tertiary prevention to ensure those with existing respiratory conditions were assisted and there

were clear pathways into and out of acute services.

Objective four addressed the project actions that would be required to implement the project as a

whole.

Box 2.1 Summary of the NRP project goal and objectives

Project goal: to reduce avoidable hospital admissions and emergency department attendances by

10% for COPD and asthma in the NAML region by 31 March 2015.

Objective One (Primary Prevention)

To minimise or prevent the occurrence of COPD and asthma for the whole NAML population and

groups at risk, specifically:

to reduce overall smoking rates in NAML residents by 2% and particularly in those most at risk

to increase health literacy about COPD and asthma

to reduce risk conditions for COPD and asthma through community settings


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Objective Two (Secondary Prevention)

To reduce or stop further damage from COPD and asthma through increased early identification

and effective management of COPD and asthma for all residents and particularly those

areas/groups most at risk

Objective Three (Tertiary Prevention)

To rehabilitate as far as possible and to reduce the likelihood of exacerbations or relapses for those

with COPD and asthma

Note effective implementation of objective two also supports tertiary prevention.

Objective Four (Coordination and Collaboration)

To establish a comprehensive coordinated whole-of-community approach to the prevention of

COPD and asthma

Figure 2.1 shows the well-established chronic disease model upon which the NRP methodology

was based and includes the underpinning enablers covered in objective four and through the other

objectives e.g. workforce development is highlighted in objective two.18,19

Figure 2.1 Prevention across the continuum of care


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Other factors informing the project methodology included:

An understanding of the impact of the social determinants of health and health inequities – large

areas of the northern Adelaide region are significantly disadvantaged. Reduced income,

intergenerational poverty, racism, isolation and poor housing conditions impact on health status

and the use of preventive health services. Individual behaviours such as smoking are also

influenced by social and economic circumstances. Addressing inequities requires

implementation of both universal and more targeted approaches which underpinned the

prioritisation of higher need communities

Health literacy – only 26% of people in disadvantaged communities will have adequate or higher

levels of health literacy.20 This requires services to respond accordingly

Certain population groups also have more risks and poorer health. The project set out to support

more vulnerable groups including Aboriginal residents, people with mental illness and those

living in locations with greater disadvantage

Creating supportive environments can make healthy choices easier – this led to the intention to

focus on different settings (schools, workplaces, local government, sport), as well as creating

supportive policies such as the comprehensive implementation of smoke-free policies in mental

health services

Recognising that there are risks that accumulate across the life course and opportunities to build

strengths and protective factors. This informed the support for several pregnancy projects and

work with schools

An understanding that enablers such as use of evidence, a data-driven approach, development

of partnerships within health and beyond are important for success

Understanding that multiple complementary approaches were required to make a difference

whilst recognising this involved large demands on the project implementation.

In summary, the project had a specific focus on enhancing responses and adapting

services/resources for those with greater levels of social disadvantage, who have poorer health,

lower health literacy, more risk factors, use less preventive health services and in locations where

higher rates of avoidable admissions are occurring.

These outcomes were to be achieved through a concerted and cooperative approach to

implementing better practice through a partnership – the Northern Respiratory Partnership –

between key local, state and national organisations and in close collaboration with the community.

PROGRAM LOGIC

The NRP program logic (Figure 2.2) sets out what the project intended to do and how it would do it,

i.e. the theory of change. It identifies the inputs, the activities to be undertaken matching the four

objectives, the expected outputs identified in the plan and the impacts that these, in turn, would

potentially have on respiratory health for individuals and the system. In turn it was anticipated that

this could result in improvements in smoking rates, hospital admissions and ED attendances as set

out in the aspirational project goal. In the longer term, should each stage be successful it is

predicted that there will be a series of outcomes related to inequities, morbidity and mortality, quality

of life and costs. It was not intended that the project would impact on these longer-term outcomes

within the project’s two-year timeframe.


18

Implicit in the logic model were a series of assumptions including:

The project actions would be implementable, and fully implemented, in the identified timelines

There would be support for the project from all of NAML and all project partners

The project coordinator would lead the work

Stakeholders would be responsive to the project including primary health care services.

Figure 2.2 Northern Respiratory Partnership Program Logic

PROJECT PLAN REVISIONS

An initial project plan was prepared prior to the project commencement in May 2013. This was then

revised in April 2014 when it became apparent that strategies were not being implemented within

the expected timelines and targets were overly ambitious. The revised plan is at Appendix 2.

Revisions included:

Some changes to targets, e.g. increase of 20% asthma training in schools and children’s

services in non-priority areas not considered feasible due to large number of services in the

area; set project reach into general practices and pharmacies in the priority locations at 40%

(decreased from 90% which was considered unrealistic)

Amended consumer consultation expectations due to time pressures and complexity of

managing multiple project strands. The extent to which consumer views would be able to

influence service design was significantly reduced


19

Removed several components due to funding changes, e.g. the Supporting smoke-free

pregnancies among Aboriginal women and their families project

Removed or modified actions due to advice from partners and stakeholders, e.g. Model of Care

and the clinical advisory committee (other mechanisms available); also workplaces very difficult

to access (Asthma SA advice) so target was kept at six

Added in actions to reflect implementation underway, e.g. included Aboriginal Round Table on

tobacco, pharmacy initiative, Improvement Foundation Quality Improvement Partnership

initiative

Clarified smoking reduction (2%) to be monitored, rather than achieved, by the NRP given wide

range of factors impacting on smoking rates

Decision to monitor available resources rather than review as very many available

Timelines adjusted throughout to reflect estimates/achievements at that time point

Clarified objectives around tertiary prevention to reflect what was occurring

Modified objective 4.4 to be more realistic to the level of engagement that seemed possible and

to remove Charter – not pursued as a more incremental approach was adopted.

PROJECT ACTIVITIES

Broadly the project undertook the following key activities to implement the project:

Progressing a series of activities in line with the project plan simultaneously, e.g. project

initiative planning (e.g. general practice respiratory clinics), organising and conducting education

sessions, liaison with providers and multiple stakeholders, follow-up actions, preparing mailouts,

developing resources, e.g. the pulmonary rehabilitation guide, etc.

Connecting up different projects and people related to respiratory health – this was a major part

of the role of the project coordinator

Providing practical assistance to primary care services, e.g. electronic Quitline referral tools,

advice on general practice client information systems

Project planning and monitoring of progress throughout; financial monitoring

Regular project reporting to funders, NAML Board and stakeholders, e.g. through NAML e-

newsletters

Contracting out specific projects – three projects received some funding support (schools and

workplaces project, asthma pharmacy referrals project), as well as some smaller initiatives, e.g.

education and awareness-raising at community events

Periodic data analysis and reporting, especially at the beginning and end of the project as well

as evidence monitoring and sharing

Supporting governance arrangements – e.g. Project Management Committee and working

groups, e.g. Hospital Working Group, Round Table Planning Group, etc.


20

THE EVALUATION

The project evaluation scope was determined by the project plan with a series of performance

indicators (process measures) and outcome measures identified for each objective as well as the

relevant data sources. Both qualitative and quantitative indicators were measured and some

progress was monitored, e.g. schools reached through asthma education; referrals to the 1800

ASTHMA infoline (phone education and support). The results are presented in this report.

Originally common tools were prescribed by ANPHA for particular measures to enable some overall

consistency of reporting across the Medicare Local projects. Most related more to changes in

individuals rather than systems and were less relevant to the NRP. The recommended VicHealth

Partnerships Analysis Tool was used for the NRP.

The intention was to apply the results and learnings from the project to inform future practice. This is

discussed in chapter 8.


21

CHAPTER 3 RESPIRATORY HOSPITAL ADMISSIONS AND EMERGENCY

DEPARTMENT ATTENDANCES

The Northern Respiratory Partnership project set an overall project goal to reduce avoidable or

preventable hospital admissions and emergency department attendances by 10% for COPD and

asthma in the Northern Adelaide Medicare Local region by 31 March 2015.

The intention was for the project implementation to be informed by data, including hospital use data,

socio-demographic indicators and general practice and other primary care data. This chapter

reports on the data used to inform the project and presents analysis of key data.

BACKGROUND - ADMISSIONS AND EMERGENCY DEPARTMENT ATTENDANCES

Hospital admissions and ED attendances are an indicator of how well conditions are being

managed by the primary health care sector and individuals.

Potentially preventable (or avoidable) admissions are defined by the Australian Institute of Health and

Welfare (AIHW) as “admissions to hospital that could have potentially been prevented through the

provision of appropriate non-hospital health services”.21 All admissions for asthma and COPD are

considered preventable. The absolute number of potentially preventable admissions is an

unsophisticated measure but provided a high-level goal for the NRP project.

The AIHW report on asthma and COPD hospitalisations comments that hospitalisation rates can

reflect demand, supply and admission practices. It states that a higher rate of hospital separations

for a particular condition may indicate:

a higher prevalence of the more severe cases of the condition that require hospital treatment

a higher prevalence of comorbidities that increase the likelihood of hospitalisation

a higher level of access to hospital (including different thresholds for admission)

less or poorer quality care available within the primary health care setting

a higher rate of re-admission to hospital due to poorer management of the condition across the hospital and non-hospital settings

a greater propensity of doctors to use diagnostic terms that are coded as asthma or COPD.22

It is important to note that ED use for non-emergency use does not constitute best care as care is

episodic rather than comprehensive. Emergency departments are used for a range of reasons –

acute emergency situations, ambulance decisions, no regular general practitioner (GP), no cost to

the patient, lack of access to after-hours care, etc. Counting the number of ED attendances is also a

basic measure because of these variables impacting on the numbers; however, it provides an ‘at-a-

glance picture’ of the demand for respiratory-related emergency care.

Ideally, if respiratory conditions were prevented or well-managed in the community through primary

care, an increased number of people would be able to deal with their asthma or COPD exacerbation

at home – potentially with additional advice from their GP, nurse or a hospital staff member –

preventing both ED attendances and admissions.

Therefore the aim was to reduce admissions and ED attendances by 10% by implementing the

range of strategies set out in the project plan, as outlined in chapter 2 and evaluated elsewhere.


22

Box 3.1 A note on the data

SA Health provided data for all residents living in the NAML region (as specified by postcodes)

attending any hospital in South Australia (SA).23 The figures relate to visits, not individuals.

The baseline used was the 2012 calendar year (referred to as 2012 in all tables) with the ‘post’ data

period being 1 April 2014 to 31 March 2015 (referred to as 2015). A full year was also required to

provide sufficient numbers to enable meaningful comparison and it was important to have the most

recent data available given the relatively short time the project had to make an impact; hence the

April 2014 to March 2015 timeframe. Trend data was also provided from 2010 onwards.

Figures are provided in relation to both ED attendances and admissions by NAML residents for

asthma, COPD and related causes. Please note, unless otherwise stated, data is provided for:

acute bronchitis, COPD, asthma and bronchiectasis. In many cases there is no significant change

between our pre and post period but the information is considered useful to provide a full picture of

the needs and service usage in the region and serves to inform future directions.

RESULTS

The overall project goal was to reduce avoidable hospital admissions and emergency

department attendances by 10% for COPD and asthma in the Northern Adelaide Medicare

Local region by 31 March 2015.

Table 3.1 shows admissions and ED attendances for both COPD and asthma. A fall of 1.7% was

achieved for ED attendances and 2.1% for admissions. Whilst this is positive there are typically

variations from year to year.

Table 3.1 Admissions and ED attendance data for asthma and COPD at project baseline

compared to final year of project

Category 2012 2015 Difference

ED Attendances 2848 2798 Minus 50 (1.7%)

Admissions 2121 2076 Minus 45 (2.1%)

The 10% figure was not based on any particular studies and was considered aspirational. Possible

reasons for not achieving this target include:

The project started in May 2013 meaning the final month of data was less than two years post the start date and the beginning of the post 12 month period April 2014 was 11 months after the start; this was shorter than originally anticipated. It was unrealistic to expect major changes in this timeframe

The northern area of Adelaide is significantly disadvantaged with poorer health, more risk factors (e.g. smoking), less use of preventive health services and lower self-efficacy. In addition, the focus for much of the NRP project effort was on service providers working with the most disadvantaged communities where change is hardest to achieve

The project worked across the continuum of care, including a focus on primary prevention directed at longer-term gains, but with little short-term impact on admissions.

The focus on general practice began mid-project thereby lessening the potential impact of primary care’s contribution to preventing admissions and ED attendances

The NRP project reach and intensity was not as great as expected so it was not likely that service responses would be sufficiently enhanced to prevent admissions


23

There were bushfires in the region that may have contributed to elevated respiratory illness and ED attendances and reduced television advertising on ED avoidance could also have contributed.

The Lyell McEwin Hospital dedicated respiratory unit did not become fully operational until late 2014.

In addition, given that almost all COPD patients are admitted to hospital from the emergency

department there is likely to be a high level of double counting. This implies that if ED attendances

were reduced there would therefore be a corresponding fall in admissions.

The PMC generally felt that the project was gaining momentum and there could be outcomes

achieved in the future – see chapter 8.

PRIORITY LOCATIONS

The hospital data was used to identify priority areas for more intensive interventions in line with the

proposed model of progressive universalism that promotes a universal approach to prevention for

the whole community with progressively more intensive support for the community proportionate to

the level of disadvantage.17

The baseline data were analysed to show the distribution across the 18 statistical local areas

(SLAs) in the NAML region for asthma and COPD (and other minor conditions) and a range of other

variables. Three SLAs were selected as the initial priorities:

Playford Elizabeth

Playford West Central, and

Salisbury Central.

Box 3.2 outlines factors taken into account in choosing these locations for more intensive

interventions.

Box 3.2 Choosing priority locations for NRP interventions

The following factors were considered in choosing the priority locations:

1 Contribution to Asthma and COPD admissions and ED attendances

The three SLAs made up 18% of the population of NAML but 25.2% and 27.7% of the asthma

admissions and ED attendances respectively and 36.5% and 41.9% of the COPD admissions and

ED attendances respectively based on 2012-13 figures. In absolute numbers the three regions are

not always ranked highest though Playford Elizabeth is highest in all regards.

2 Disadvantage

The NRP project focus on disadvantage meant prioritising more disadvantaged SLAs, based on the

Index of Relative Socio-economic Disadvantage (IRSD) scoreii, over more advantaged. The three

priorities were in the top decile for disadvantage in SA and Australia.

ii Index of Relative Socio-economic Disadvantage (IRSD) is based on variables including: proportion of low income households in the area; proportion

of people who do not speak English well; proportion of households who pay low rent; and proportion of people with no post-school qualifications.


24

3 Impact on the aim

Consideration was given to the size of the population, as SLAs that were too small would not have

sufficient population sizes to impact on the goal. The three chosen were ranked 6th, 12th and 4th in

size within NAML, thus constituting 18% of the population.

4 Mortality data

Data provided by the Public Health Information Development Unit (PHIDU) on premature mortality

for respiratory health (ranked 1st, 2nd and 3rd) and deaths aged 45-74 years for COPD (ranked 1st, 3rd

and 4th) supported selecting these priority locations.24

5 Age

The selected areas are not particularly older demographics being ranked 3rd, 8th and 14th within

NAML. Thus it is not age that was a particular contributor to the high numbers.

6 Aboriginality

The three areas have high rates of Aboriginal and Torres Strait Islander people, being ranked 1st, 3rd

and 5th within the NAML region and comprising 33.5% of the entire NAML Aboriginal and Torres

Strait Islander population. The high rates of smoking in Aboriginal people and the higher rates of

poor health made this a priority population.

7 Project model

The project originally included a performance indicator to achieve 90% participation in practice

improvement initiatives by general practices and pharmacies in priority locations. This was later

amended to 40% participation in some practice improvement initiatives. The intensive nature of the

intervention in priority areas meant it was necessary to limit the size and number of areas.

On this basis, the three areas were selected as the priority locations.

EMERGENCY DEPARTMENT (ED) ATTENDANCES

Figure 3.1 shows ED attendances for COPD and asthma combined, by the 18 SLAs, with the

disparities in attendance for the three SLAs continuing over time. In 2015:

Playford Elizabeth had 12.1% of ED attendances (N=341) but 6.5% of the population

Playford West Central had 8.0% of ED attendances (N=223) but 4.2% of the population

Salisbury Central had 9.4% of ED attendances (N=264) but 7.3% of the population.


25

Figure 3.1 Emergency department presentations, by SLAs, in the NAML region 2010-2015

Asthma / COPD breakdown

Considering only the ED attendances coded ‘asthma’ or ‘COPD’ (i.e. excluding bronchiectasis and

acute bronchitis), 63.3% of these were for COPD and 36.7% were for asthma.

ED attendances, by hospital

The following table shows the proportion of ED attendances at the key major hospitals serving the

region. The Lyell McEwin Hospital (LMH) is consistently the major ED visited by people living in the

NAML region.

Table 3.2 Emergency department use by hospital 2012 and 2015

Hospital 2012 2015

Number % Number %

Gawler 57 2.0 99 3.5

LMH 1475 51.8 1448 51.8

Modbury 716 25.1 681 24.3

RAH 187 6.6 193 6.9

TQEH 33 1.2 43 1.5

WCH – Paed ED 360 12.6 286 10.2

Others 20 0.7 48 1.7

TOTAL 2848 100% 2798 100%

NB: LMH = Lyell McEwin Hospital; RAH = Royal Adelaide Hospital; TQEH = The Queen Elizabeth

Hospital; WCH – Paed ED = Women’s & Children’s Hospital – Paediatric ED


26

Aboriginal health

Aboriginal and Torres Strait Islander people made up 3.9% in 2012 and 4.4% in 2015 of all ED

attendances in the NAML region. The 2011 census shows 7,321 Aboriginal & Torres Strait Islander

people live in the NAML region; 1.8% of the NAML population. Aboriginal and Torres Strait Islander

people are concentrated in 4-6 SLAs, with 14.2% of the region’s Aboriginal people living in Playford

Elizabeth SLA. Use of ED is therefore disproportionately high.

Age

Table 3.3 shows use of ED, by age group, comparing baseline with recent data; there are no

discernible trends. Children aged 0-14 years comprise around one third of all respiratory related ED

attendances all of which are for asthma.

Table 3.3 Emergency department use, by age group, 2012 and 2015

Age (years) 2012 % 2015 %

0-14 996 35.0 925 33.1

15-65 1068 37.5 1057 37.8

65+ 784 27.5 816 29.2

TOTAL 2848 100% 2798 100%

SA Health data also shows that 29.0% of ED attendances for children aged less than 15 years are

to the Women’s and Children’s Hospital, with 46.7% to LMH and 18.7% to Modbury Hospital. The

NRP did not work with the Women’s and Children’s Hospital and this would be an area for future

development.

For NAML residents aged over 65 years who attended an ED in the region, 57.4% attended LMH

ED in 2015 (down from 58.4% in 2012) and 28.6% attended Modbury ED, up from 26.9% in 2012.

Nearly 90% of ED attendances were self-referred, with 6.3% referred by their GP in 2015.

Triage category

Graphs in this section show triage category 4 and 5 ED attendances for asthma, COPD, acute

bronchitis and bronchiectasis. Triage categories 4 and 5 indicate ED attendances that are less

urgent and less acute and could potentially have been dealt with by general practice. However, it is

also likely that they reflect proximity as suggested by the figures for Gawler and Playford Elizabeth

which are both near to the hospital. Figure 3.2 shows ED presentations by SLA.


27

Figure 3.2 Triage categories 4 and 5 emergency department presentations, 2012 and 2015

Table 3.4 Triage category – 2012 to 2015

Triage Category Presentation calendar year

2012 2013 2014 2015

# % # % # % # %

1 83 2.9 127 4.6 127 4.7 145 5.2

2 645 22.6 744 26.8 778 28.5 761 27.2

3 1778 62.4 1600 57.7 1508 55.3 1574 56.3

4 320 11.2 284 10.2 297 10.9 297 10.6

5 22 0.8 20 0.7 19 0.7 21 0.8

TOTAL 2,848 100% 2,775 100% 2,729 100% 2,798 100%

In 2014-15, 11.4% of ED attendances for asthma, COPD, acute bronchitis and bronchiectasis were

for triage category 4 or 5 suggesting potential for these cases to be managed in primary care.

Not surprisingly, a higher proportion of young people were included in the higher triage category.


28

Table 3.5 Emergency presentations by age total 2012, 2013, 2014, 2015 (3 months) combined

Age Groups (years) Triage Category 4 Triage Category 5

# % # %

0-14 429 45.0 10 15.2

15-64 397 41.7 45 68.2

65+ 127 13.3 11 16.7

TOTAL 953 100.0% 66 100.0%

Monday was the most popular day for ED attendances across the years.

Table 3.6 ED presentations by diagnosis (broad group), by year, by after-hours status

Presentation calendar year 2012 2013 2014 2015

Diagnosis (broad group) # % # % # % # %

Acute bronchitis 79 4.5 48 2.8 54 3.3 36 2.9

Asthma 1,142 65.1 1,178 68.0 1,027 62.9 791 63.5

Bronchiectasis 8 0.5 6 0.3 7 0.4 5 0.4

COPD 526 30.0 501 28.9 546 33.4 413 33.2%

TOTAL 1,755 100% 1,733 100% 1,634 100% 1,245 100%

Rates of ED attendances for asthma are often considered to reflect the prevalence of severe or

poorly controlled asthma in the community and some with severe or poorly controlled asthma have

frequent visits. Asthma Australia note that the group most likely to go to an emergency department

for asthma treatment is children aged 0-14 years, and they are most likely to attend in late summer

(February). Around 40% of people who attend an emergency department for asthma treatment are

admitted to hospital.

Table 3.6 shows that 63.5% of after-hours visits are for asthma, down slightly from 2012, with one-

third of visits for COPD.

Asthma is responsible for a slightly larger proportion of ED attendances (53.1%) from the three

priority SLAs. The LMH is used for 89% of these attendances.

Table 3.7 NRP priority SLAs by diagnosis

Apr 2014 - Mar 2015 Diagnosis*

SLA Asthma Bronchiectasis COPD Grand Total

Number Number Number

Playford (C) - Elizabeth 160 3 168 331

Playford (C) - West Central 123 4 91 218

Salisbury (C) - Central 146 3 110 259

Grand Total 429 10 369 808

% 53.1 1.2 45.7

*Excludes Acute Bronchitis


29

HOSPITAL ADMISSIONS

There were 2121 admissions in total in 2012 and 2076 in 2015, a fall of 2.1% which is not

statistically significant.

Figure 3.3 shows hospital admissions by the 18 SLAs, with the disparities in admissions for the

three SLAs continuing over time. In 2015:

Playford Elizabeth had 12.8% of hospital admissions (N=266) but 6.5% of the population

Playford West Central had 7.7% of hospital admissions (N=159) but 4.2% of the population

Salisbury Central had 9.8% of hospital admissions (N=204) but 7.3% of the population.

Figure 3.3 Hospital admissions, by SLAs, in the NAML region, 2010-2015

Breakdown of admissions

Table 3.8 shows the breakdown in admissions between asthma, COPD and bronchitis. There is a

slight fall in asthma admissions and rise in COPD admissions.

Table 3.8 Admissions for asthma, COPD and bronchiectasis / acute bronchitis 2012 and

2014-15

Principle diagnosis (grouped)

Separation calendar year

2012 2015

# % # %

Asthma 804 37.9 713 34.3

Bronchiectasis (and acute bronchitis)

27 1.2 41 2.0

COPD (inc Emphysema) 1290 60.8 1322 63.7

TOTAL 2121 100% 2076 100%


30

Aboriginal health

Aboriginal and Torres Strait Islander people made up 3.1% of hospital admissions in 2012 and 3.3%

in 2015; this compares with the population rate of 1.8% in the NAML region. There were only 68

admissions in 2015 and the figure is quite consistent over the years.

Acute bronchitis is excluded and small numbers have been deleted from the table.

Hospital used

The following table shows the proportion of admissions at the major hospitals serving the region.

The Lyell McEwin is consistently the major hospital used with 50.6% of the total admissions in 2012

and 53.6% in 2015. The Royal Adelaide Hospital was used by 10.0% in 2015 but this is expected to

fall as LMH beds are now available in the new dedicated respiratory ward.

Table 3.9 Admissions by hospital, 2012 and 2015

2012 2015

Hospital # % # %

Gawler 100 4.7 138 6.6

LMH 1073 50.6 1112 53.6

Modbury 511 24.1 406 19.6

RAH 174 8.2 208 10.0

TQEH 41 1.9 29 1.4

WCH 201 9.5 145 7.0

Others 21 1.0 38 1.8

TOTAL 2121 100% 2076 100%

NB: LMH = Lyell McEwin Hospital; RAH = Royal Adelaide Hospital; TQEH = The Queen Elizabeth

Hospital; WCH – Paed ED = Women’s & Children’s Hospital – Paediatric ED

Age

Children comprise around 20% of all respiratory-related (predominantly asthma) admissions, less

than the 33.1% for ED attendances. Data also shows that 39% of admissions for children aged less

than 15 years were to the Women’s and Children’s Hospital in 2012, with 50.6% to LMH and 19.3%

to Modbury. For the 2015 period this is 35.3% to Women’s and Children’s Hospital, 54.9% to LMH

and a significant fall with 5.3% to Modbury.

People over 65 years comprised 49.2% of all admissions (47.4% in 2012), with half going to the

LMH; the majority of these would be for COPD.

Table 3.10 Admissions by age, 2012 and 2015

2012 2015

Age (yrs) # % # %

0-14 498 22.7 397 19.1

15-64 616 28.1 657 31.6

65+ 1007 45.9 1022 49.2

TOTAL 2,192 100.0% 2,076 100.0%


31

Figure 3.4 Data for inpatient length of stay for both conditions combined

Hospitals are generally trying to reduce their Average Length of Stay (ALOS) – the average number

of days a patient might expect to spend in hospital for a particular procedure or diagnosis – whilst

not compromising care or raising readmission rates. There are a high number of single day

admissions and a proportion of these are likely to be able to be managed in primary care due to it

being likely that they are of lower acuity. Hospitals can compare their performance with comparators

using Health Roundtable data and this can contribute to reviewing respiratory practice.

SUMMARY

There have been small reductions in COPD and asthma admissions and ED attendances over the

period of the NRP project.

The disproportionate contribution to asthma and COPD admissions and ED attendances of three

SLAs in the region helped the NRP to prioritise the areas for enhanced attention. Table 3.11 shows

that there have been improvements in eight of the twelve indicators which is positive. All four

indicators for Playford Elizabeth have improved. The NRP may have contributed to this change but

the changes are small and do vary across years.


32

Table 3.11 Contribution of three priority areas to hospital admissions and ED attendances for

asthma and COPD

Asthma COPD

Region (%) of NAML population Admissions(%) ED (%) Admissions(%) ED (%)

Playford Elizabeth (6.5%)

2012 9.5 10.7 16.4 20.4

2015 8.7 9.5 15.1 17.1

Playford West Central (4.2%)

2012 6.7 8.5 8.3 8.5

2015 8.3 7.3 7.3 9.3

Salisbury Central (7.3%)

2012 8.5 9.1 11.2 10.9

2015 9.0 8.6 10.5 11.2


33

CHAPTER 4 OBJECTIVE 1 PRIMARY PREVENTION

This chapter and the following three chapters report on the implementation of project activities

(purple boxes) and achievements against project objectives (blue boxes).

Objective 1 is focused on primary prevention i.e. keeping people well through addressing the

upstream determinants of poor health. This includes both the key risk factor for COPD and

contributor to poor asthma outcomes, smoking, as well as addressing health literacy and reducing

risk conditions through increasing supportive and healthy environments in which people live, work

and play.

Smoking is a major risk factor for chronic respiratory conditions including asthma and COPD.25

Smoking makes asthma worse and asthma control more difficult; it may increase the frequency of

flare-ups (attacks) and decrease the effectiveness of medication.26 Asthma in children has been

associated with secondhand smoking.27 In Australia smoking is the major cause of COPD. Around

27% of smoking-related deaths are due to COPD.28 For these reasons a focus on preventing

smoking was fundamental to the NRP.

SMOKING RATES IN THE NAML REGION

The NRP set a key indicator of reducing smoking rates in the NAML region by 2%, recognising that

this could not be directly attributable to the NRP intervention given the range of interventions

underway nationally and across SA and the limited scale of the NRP. The expectation however was

that the NRP project activities would contribute to a reduction in smoking rates.

Smoking rates in the NAML region have decreased

As shown in Table 4.1, within the NAML region there was a statistically significant decline in smoking rates between 2012 and 2014:

From 20.1% to 15.5% in all smokers

From 17.5% to 9.3% in 15-29 year olds

Objective 1 To minimise or prevent the occurrence of COPD and asthma for the whole NAML

population and groups at risk and specifically:

Obj 1.1 To reduce overall smoking rates in NAML residents by 2% and particularly those

groups at risk

Obj 1.2 To increase health literacy about COPD and asthma

Obj 1.3 to reduce risk conditions for COPD and asthma through community settings


34

Table 4.1 Smoking prevalence for those aged 15 years and over living in the NAML region,

2012 to 2014 from the Health Omnibus Survey (see Box 4.1)

2012 2014

Type of smoker Smoking prevalence

Sample size

95%CI (a) Smoking prevalence

Sample size

95%CI (a) Sig 2012-2014

NAML % (n) % (n)

Total All smokers (b) (15 years +) 20.1 691 16.5 - 23.7 15.5 661 12.2 - 18.8 0.03

Total Daily smokers (b) (15 years +) 17.5 691 14.1 - 20.9 13.9 661 10.7 - 17.1

South Australia

Total All smokers (b) (15 years +) 16.7 3051 15.1 - 18.3 15.7 2731 14.1 - 17.3

Total Daily smokers (b) (15 years +) 14.4 3050 12.9 - 15.9 12.8 2730 11.3 - 14.3

Daily smokers only

Age Groups

15-29 years 17.5 183 10.9 - 24.1 9.3 194 4.4 - 14.2 0.02

30-44 years 25.7 183 18.1 - 33.3 17.8 152 10.5 - 25.1

45-59 years 20.6 165 13.2 - 28.0 20.5 156 12.9 - 28.1

60+ years 5.6 161 1.3 - 9.9 9.4 159 4.0 - 14.8

Socio-economic disadvantage quintiles

Quintile 1 (most disadvantage) 23.8 235 17.3 - 30.3 18.2 209 11.9 - 24.5

Quintile 2 15.8 177 9.4 - 22.2 12 175 6.2 - 17.8

Quintile 3 17.6 51 5.1 - 30.1 13.5 74 4.2 - 22.8

Quintile 4 12.6 207 7.2 - 18.0 11.2 169 5.5 - 16.9

Quintile 5 (least disadvantage) 14.3 21 0.0 - 32.3 11.8 34 0.0 - 24.8

(a) Standard errors used to create confidence intervals are inflated to reflect clustered sampling techniques used in the Health Omnibus Survey. (b) 95% confidence intervals indicates the range of values that are likely to be trued (with 95% certainty) at the population level. (c) All smokers refers to participants who reported smoking either daily, weekly or less often than weekly.

Table 4.1 shows a 4.6% fall in smoking rates for all smokers within the NAML region from 20.1% in

2012 to 15.5% in 2014. This compares favourably with the fall in the statewide rate from 16.7% in

2012 to 15.7% in 2014.

Daily smoking rates in NAML have fallen from 17.5% to 13.9% over the same time period but this is

not significant. The fall in smoking amongst younger people is particularly important as this reduces

the chances this group will go on to be smokers and reduces children’s exposure to secondhand

smoke.

Nationally, people (14 years or older) living in the lowest socio-economic status (SES) areas were

three times more likely to smoke daily than people with the highest SES, 19.9% compared with

6.7%.29 Within the NAML region the smoking rate ranged from 14.3% to 23.8% across the five

quintiles of socio-economic disadvantage in 2012, falling to 11.8% to 18.2% respectively in 2014

however this was not statistically significant.

Box 4.1 A note on the smoking data

Smoking data in this section are drawn from the SA Health Omnibus Survey, a statewide, annual

household survey conducted via face-to-face interviews each year.30 Please note that the small

sample sizes have resulted in very large confidence intervals (and insufficient numbers to determine

statistically significant differences) for many of the smoking rates reported in Table 4.1. Caution

should be taken in drawing conclusions.

Smoking is measured in different ways by different surveys. The 2011-13 Australian Bureau of

Statistics (ABS) National Health Survey also surveys those aged 15 years and over face-to-face.

Results show a smoking rate of 18% for NAML31,32 This is the fifth worst of the 27 metropolitan


35

Medicare Locals around Australia. Smoking rates ranged from 6% to 28% across all Medicare

Locals.

It is difficult to determine the impact of any one strategy on smoking rates but the increase in

smoking rates in 2013 has been attributed to significant reduction in anti-tobacco social marketing

that took place in 2012-13. This was reversed in August 2014 and it is believed this contributed to

lower rates later in 2014 through to 2015. Other factors impacting on smoking rates may include:

tax increases (excise) totalling 50% over four years, including December 2013 and September

2014

social marketing campaigns

introduction of tobacco plain packaging nationally and updated and expanded graphic health

warnings (2012)

reduced opportunity to smoke and smoke-free zones, e.g. in hotels and other public places, etc.

access to support to quit

point of sale policies – tobacco has been completely ‘out of sight’ at general tobacco retailers

since 1 January 2012 (and at specialist tobacconists since January 2015).

Aboriginal and Torres Strait Islander South Australians – smoking rates

The NRP indicated it would monitor smoking rates for the Aboriginal and Torres Strait Islander

community but acknowledged that it was not possible to measure the rate at the NAML region level

nor was it expected that it would be able to influence this rate to any significant degree.

The SA smoking rates given in the 2012-13 ABS National Health Survey showed 42.2% of

Aboriginal and Torres Strait Islander people aged 18 years and over (age standardised) were

current daily smokers.33 This compares directly with a rate of 47% (age standardised) in 2008 for

SA.34 This fall is encouraging and should contribute to reducing the prevalence and incidence of

both asthma and COPD in South Australia.

Smoking in higher risk groups

It was also agreed the NRP would monitor smoking rates for at-risk groups. Smoking in pregnancy

is an important indicator as this can be a critical time to quit smoking especially given that smoking

around children contributes to respiratory illness.

People with mental illness have an overall death rate 2.5 times higher than that of the general

population and a life expectancy between 15 to 25 years less – this is at least partly due to smoking.

Smoking rates in people with a mental illness can be between 50% and 80% compared with less

than 20% in the community as a whole. In Australia it is estimated that more than 42% of all

cigarettes are smoked by people with mental illness. Smoking compounds disadvantage and can

interfere with treatments for mental illnesses.35 People with a mental illness have more difficulty

self-managing respiratory conditions and smoking exacerbates this problem. It is not possible to get

regional data on smoking and mental illness.

IMPLEMENTATION OF KEY ACTIVITIES

Smoking prevention activities identified in the NRP project plan were:

Community education re smoking to the whole population and specifically to those with asthma or COPD (and their families), and high risk groups

Develop and encourage anti-smoking policies e.g. health services, public spaces


36

Assist individuals to quit smoking (also relates to objective 2.1 below)

Support for a more coordinated approach to quit services/tools for Aboriginal and Torres Strait Islander residents.

Community education on smoking

The intention of the NRP was to undertake community education throughout the project on the

harms of smoking and the connection with asthma and COPD. Community education covers

activities on World No Tobacco Day, local promotion of state and national campaigns, local media

and opportunistic promotions. This was to focus on the community as a whole and groups at risk to

both prevent the uptake of smoking and support people to quit, especially those with respiratory

conditions.

In October 2013, NAML made the decision to prioritise ‘quit smoking’ messages as a major

community engagement activity for the organisation, at least partly due to the clear alignment with

the NRP project. A region-wide survey was undertaken to better understand the knowledge,

attitudes and beliefs of the NAML population in regards to smoking and smoking behaviours.

Surveys were administered at shopping centres, general practices, community events and other

locations and completed by 598 respondents. Results showed:

nearly 21% of the total respondents were current smokers, including those currently trying or

planning to quit

49% of non-/ex-smokers self-rated their health status to be very healthy and healthy, in

comparison to 25% of current smokers

64% agreed it is difficult to stop smoking

49% believe smoking helps them to relax

52% want to improve their own health

51% believe it costs too much to quit

46% said becoming pregnant or starting a family would help them quit.

In terms of knowledge the survey found that 24% of people surveyed believed that advice from

health workers (i.e. doctors, nurses, social workers, psychologists, etc.) would help people who

want to quit smoking. Table 4.2 shows which health services they indicated would be helpful.

Table 4.2 Awareness of options that would help people to quit smoking

Options^ Percentage respondents who chose each option^

Free support from Quitline 84.0

Over-the-counter nicotine replacement therapies 77.0

Support from health workers 68.0

Prescription medications (e.g. Champix, Zyban, etc.) 62.1

Information and resources on the internet 53.7

Other reasons 6.7

None of the given reasons 4.2

N=594 (excludes missing values)

^Respondents were allowed to select more than one response and the total percentage does not

equate to 100 percent.


37

The results provided useful consumer insights into reasons for smoking, barriers to quitting,

knowledge of services, etc. which helped inform content provided at education sessions and to

practitioners such as pharmacists. A summary was distributed in the July 2014 NAML e-newsletter

and provided to DASSA for information.

A number of other community education activities were undertaken over the course of the NRP

project, predominantly focused on Aboriginal communities (see below).

Anti-smoking policies

Reducing smoking relies in part on a whole-of-community response to addressing smoking and

implementation of smoke-free policies are an important part of this. The NRP’s intention was to work

with organisations to develop and implement policies, e.g. smoke-free zones in community facilities

and events as well encouraging supportive environments in health and community services and

workplaces to ensure they had smoke-free policies in place and were supporting staff and clients to

quit.

In terms of organisations the NALHN is required to comply with the 2013 statewide SA Health

Smoke-free Policy Directive. The policy directive aims to protect the health of all persons entering

SA Health premises by prohibiting smoking, and providing assistance to staff and consumers who

wish to address their tobacco smoking.36 Through participation in the NRP, NALHN met with

Quitline staff in early 2015 to identify further ways in which additional action might be taken to

support consumers and staff to quit smoking. This meeting led to the Quitline Team Leader

(Quitline’s representative on the NRP PMC) being invited to present at NALHN All Staff Forums in

May 2015, as well as meeting with hospital pharmacy staff. A promotion was held at the Lyell

McEwin Hospital on 29 May 2015 in recognition of World No Tobacco Day. Quitline staff spoke to

many staff and visitors, and gained five referrals to their service through these conversations.

Box 4.2 What else will the NALHN progress to support consumers and staff to quit smoking

and to prevent uptake? Results from NRP partner discussions:

Explore the potential to embed Quitline referral forms into NALHN electronic systems to make

referral quick and easy

Distribute the Quitline resources and referral information (with reordering arrangements) through

NALHN communication systems (newsletters, emails, etc.)

Highlight units or staff groups that have made significant numbers of referrals to the Quitline,

e.g. there have been 74 referrals from hospital midwives in 12 months

Offer smoking cessation training (information sessions and/or Quitskills) to NALHN staff

including Aboriginal health service staff

Develop a referral pathway to support staff leading quit smoking work including close liaison

with a Quitline counsellor and support for a ‘warm hand over’ for patients to Quitline where the

staff member rings Quitline with the patient prior to discharge or separation from the point of

care

Quitline counsellor to visit NALHN hospitals and agencies to build connections and increase

knowledge

Explore opportunities for Quitline to participate in NALHN Work Health Safety health and

wellbeing activities


38

Assisting people to quit

This was an important area for attention for the NRP. The focus was on reminding service providers

about the connection between smoking and respiratory conditions and providing them with skills to

discuss smoking with their clients and assist them to quit. There is clear evidence that advice from

health professionals such as GPs and practice nurses to support quitting is effective.37

Quit smoking information was included in most education sessions for service providers. For

example pharmacists who attended training to implement the asthma components of the pharmacy

initiative received information from the Quitline Team Leader and a Quitline representative spoke at

the GP consultation in late 2013.

Specific smoking cessation training for providers included:

Support for six pharmacists to attend Pharmaceutical Society of Australia (PSA) SA/NT Branch

motivational interviewing event (June 2013)

Seven Aboriginal Health staff and two health promotion staff at NAML and NALHN received

smoking cessation training, which included information about nicotine addiction, nicotine

replacement therapy products and motivational interviewing (September 2013)

All pharmacies (83) and GPs (93) in the NAML region were provided with information on the

Quitline (see objective 2).

Quitline, PSA and NAML ran a smoking cessation workshop for pharmacists and pharmacy

assistants in September 2014. Twenty-four pharmacists and pharmacy assistants from a range

of local community and hospital pharmacies attended. The workshop featured Associate

Professor John Litt from Flinders University, who shared his knowledge and experiences in

relation to nicotine addiction and applying motivational interviewing techniques. Attendees

reported that the session was valuable to their work and would enable them to support their

customers’ attempts to quit smoking confidently.

A smoking cessation workshop was held with 20 GPs and practice nurses attending (April 2015)

Quitline visits to general practices to upskill staff on brief interventions with patients about

quitting smoking are planned for the second half of 2015

Quitline presented to 20 LMH pharmacists to encourage further referrals to Quitline in the future

as well as NALHN staff at Modbury Hospital.

Quitline created shelf-wobbler health

promotion aids for display next to nicotine

replacement therapy (NRT) products in

pharmacy stores in the NAML region (see

image right). Their production was sponsored

by the NRP and they were distributed to

attendees of the smoking cessation workshop

for pharmacists. Lung Foundation Australia

also provided shelf wobblers for placement

near the NRT products; these were used as

part of the World COPD Day promotions.

To assist general practices to refer people who smoke to the Quitline, NAML created electronic

Quitline referral templates for importing into ZedMed, Best Practice, Medical Director and

MedTech32 medical software. These have now been installed in 17 general practices in the


39

region. Furthermore, all practices in the NAML region were advised by letter that NAML is able to

assist set-up an electronic referral process to Quitline and that the NRP Project Coordinator could

be contacted to arrange this.

18% of practices now have electronic Quitline referral templates

Pharmacies were also advised that the Guildcare software has a prompt to initiate a lung health

checklist when someone has scripts for Zyban and Champix (both prescription medications to assist

with quitting smoking).

There was no significant action in relation to assisting services to help people with a mental illness

to quit smoking. There were several reasons for this: it was not easy to identify the best strategies;

attention was directed to other NRP activities; and, where some discussions were held, there was

no significant progress made. Partners who may have been able to help in this area were also

facing organisational changes, limiting capacity to assist. See Proposed Way Forward.

The Quitline

Research shows that the Quitline call-back service can significantly increase a smoker’s chance of

quitting. Around 40% of smokers who use Quitline’s call-back service successfully have quit

smoking on follow-up after six months. Many people quit smoking ‘cold turkey’, others use

pharmacotherapy or online tools but the Quitline provides an evidence-based service that can

double the success rate of quitting compared to quitting without support.38 Encouraging a range of

providers (pharmacists, nurses, GPs and others) to refer to the Quitline was a key strategy of the

NRP project. It was therefore important to track rates of referrals.

The NRP evaluation compared data for the three months of January, February and March 2015 with

the same period in 2013. Table 4.3 shows the results. Overall the numbers have fallen slightly

however this is primarily due to falls in self-referrals which correlates strongly with the presence of

anti-tobacco social marketing which was still high in early 2013. Smoking rates have also fallen,

reducing the number of potential callers. The numbers from general practice have not changed

significantly but it is expected this will change as more have the electronic referral templates

available in their software. Overall, general practice referrals make up about three-quarters of those

referred.

In Jan-Mar 2015 the top three referring general practices in the NAML area have all been

involved with the NRP

Table 4.3 Source of referral for NAML residents contacted by the Quitline, 2013 and 2015

Referral Sources Jan-Mar 2013 Jan-Mar 2015

Hospitals 21 35

Correctional services 24 34

Pharmacy 0 1

General practice 236 227

Other 12 16

Subtotal 293 313

Self-referral 99 66

Total 392 379


40

Pharmacy figures are very low however analysis of Quitline data showed there were nine referrals

from NAML pharmacies (out of 28 across SA) in the period 1 January 2014 to 28 February 2015

compared with zero from the NAML region in 2013. All pharmacy referrals were from pharmacies

involved in the NRP. Statewide in the same period there were 16 referrals from pharmacies in

hospitals, none of which were in the NAML area. This reinforces the importance of the work

commenced by the Quitline with NALHN hospitals.

There were 17 Aboriginal people living in the NAML region who were contacted by the Quitline in

the same three months of 2013 and 22 in the 2015 period.

Working with Aboriginal communities

Assisting Aboriginal and Torres Strait Islander residents to quit smoking and preventing uptake in

the first place was a key focus for this project. Smoking is a major contributor to poor respiratory

health as well as other health conditions and contributes to financial difficulties. High smoking levels

are the result of multiple factors, including disempowerment, social norms, community and family

stress and low self-efficacy. There are multiple agencies in a position to encourage and support

Aboriginal people to quit but there were opportunities to have a more coordinated and

comprehensive regional approach to meet the quit smoking needs of Aboriginal people and develop

a more coordinated approach to services and resources. Sharing the extensive social marketing

strategies was also important.

To this end a Tobacco Round Table meeting was held 8 April 2014 with around 20 people attending

from a range of organisations including NAML, NALHN, Aboriginal Community Controlled services,

peak bodies, DASSA, Quitline, etc.

The goals were:

To contribute to maximising the provision of comprehensive, coordinated and appropriate

services and programs to increase Aboriginal engagement with smoking cessation services and

therefore support smoking cessation.

To bring together people who have the opportunity to assist Aboriginal people to quit smoking.

In terms of objectives, participants were to identify: the availability of and gaps in cessation services

to support quitting; ways to maximise service usage including existing barriers to quitting; options to

better link up community services (e.g. NGOs) with tobacco services; and specific actions that could

be developed to support Aboriginal people to quit smoking.

The Round Table was successful in providing information to participants about the history of

smoking and why rates are high for Aboriginal people as well as up-to-date information on what

works to assist people to quit or not start smoking. A working group was established and made

progress on key recommendations as follows:

Further enhancement of partnerships: working together around services and clients: general

practices in the NAML region that have registered for the Closing the Gap (CTG) Indigenous

Health Incentives Practice Incentive Payment became a focus for increased efforts to support

Aboriginal smokers to quit.

Increasing cultural competence around quitting for health professionals, health services and

others: NAML mailed out a smoking cessation support package to all general practices in the

NAML region in December 2014. The contents of the package were put together by DASSA,

Quitline and NAML and contained DASSA’s Give up smokes for good anti-smoking campaign

materials (targeted to Aboriginal and Torres Strait Islander people), Quitline’s Aboriginal-


41

specific services information brochures, latest Pharmaceutical Benefits Scheme

pharmacotherapy fact sheet, and some evidence and facts about ‘what works’ in supporting quit

attempts and successful quitting (see figure 4.1). Evidence was also included showing that a

high proportion of the community living in northern metropolitan Adelaide are considering

quitting in the next six months and/or have attempted to quit in the preceding six months.

Practices registered for CTG received additional information, e.g. information slides that can be

displayed through digital screens in practice reception areas. No feedback was received on this

package from the practices.

Training, including enhanced promotion of currently available training (around providing quit

support), and training for mainstream partners: the NRP has provided resources to CTG-

registered practices as well as all mainstream services.

Enhanced collaboration and coordination between services to clarify what needs to happen to

support Aboriginal smokers making a quit attempt: this has not been formally progressed though

there has been some collaborative work. At the NAML Community BBQ held to recognise

National Close the Gap Day in March 2015, the NRP Project Coordinator promoted Quitline and

its Aboriginal-specific service, as well as the Nunkuwarrin Yunti Tackling Tobacco program –

brochures about these services were distributed to other service providers working with

Aboriginal clients and referrals to these services were discussed. These same brochures were

also provided to general practices in the NAML region through the mailout noted above.

The package sent to general practices (above) also helped link services including Quitline,

Nunkuwarrin Yunti and DASSA through sharing of information and referral numbers.

Asthma SA also distributed DASSA and Quitline resources at various expos, training and

education sessions, community events, as well as activities relating to the Asthma Assist

Services where face-to-face consultations are often conducted. Asthma SA works in close

consultation with the Aboriginal Health Council of SA Inc. in reaching Aboriginal Australians who

are living with respiratory illness and those who smoke.

Templates available and/or developed to ensure effective and easy referral processes and

improved connections with, and referral pathways for, NGOs: the intention was to develop a

smoking cessation services ‘pack’ or ‘kit’ that would contain a client journey map and the various

referral templates available. This kit could be distributed to NGOs, such as Asthma SA,

Anglicare and Centacare, financial counselling services and state government departments, e.g.

Housing SA. To date this has not been progressed due to time and resource constraints.


42

Figure 4.1 Fact sheet on reducing smoking for Aboriginal and Torres Strait Islander People

The level of engagement of Aboriginal Health Workers (AHWs) was included in the NRP project

plan as a performance indicator. Through the NRP project coordinator, NAML AHWs were involved

in supporting the project (both smoking-related and more generally) in a number of ways including:

Seven members of the CTG team attended a Quitskills one-day workshop September 2013

NAML CTG Care Coordination Nurses and

Aboriginal Outreach Workers attended

training run by the Aboriginal Health Council

of SA Inc. in use of a Smokerlyzer (a

compact personal carbon monoxide breath

test monitor; see image right) in August

2014 and this was subsequently used to

assist quitting conversations with smokers

at the SA Aboriginal Football and Netball

Carnival and also by NAML health

promotion staff at community events

Reviewing their client list to identify those with respiratory conditions and inviting them to attend

the Lung Foundation Australia Patient Education Day in November 2014

Preparing information slides for digital screens in practice reception areas (DASSA and NAML

CTG) and reviewing materials to be mailed out in the smoking cessation resource package for

general practices

Facilitating the NRP Project Coordinator’s attendance at the NAML CTG Community BBQ to

have quitting conversations with smokers and to promote Quitline and its Aboriginal-specific

service, as well as the Nunkuwarrin Yunti Tackling Tobacco program


43

One AHW representing NAML at a statewide Aboriginal tobacco forum facilitated by Quitline in

April 2015

CTG Care Coordination Nurses supporting development of a package of patient information

resources for clients with COPD (also to develop a pack for clients with asthma but this has not

commenced yet)

The NRP also broke down barriers and supported a longer term partnership around Aboriginal

health and quit smoking by connecting DASSA and Quitline with the CTG team and adding value to

the work of both through cross-promotion.

The Supporting smoke-free pregnancies among Aboriginal women and their families project was

designed to provide more intensive quitting support, including trialling financial incentives, for

Aboriginal women. It was due to be funded by the state government however funding was

withdrawn as part of budget pressures. As a result of the NRP, DASSA, NAML and the South

Australian Health and Medical Research Institute (SAHMRI) have met to establish a process to

develop a proposed research methodology, identify potential partners in the project and to explore

funding opportunities for research.

In a similar vein a major university-based research project on asthma and pregnancy (for pregnant

women attending Lyell McEwin Hospital), which included assistance to quit smoking, also had state

government funding withdrawn further reducing the support for pregnant women in the region.

SUMMARY

Prevention of smoking and assisting people to quit is vital for respiratory health and many other

reasons. The scope of work was purposely ambitious and whilst not all of the intended outcomes

were achieved in full, key successes included extensive support for general practice to refer

patients to Quitline and the practical inclusion of the electronic template, increased promotion of

Quitline’s Aboriginal-specific service by NAML, planning of strategies at the NALHN and greatly

enhanced collaboration between the project partners on smoking.

The proposal for local tobacco awareness-raising action was based on the intention to embed

statewide tobacco control messages at the local level. Funding reductions to tobacco-related social

marketing and communications at the state level in 2013 and early 2014 made this more difficult.

These cuts also reduced the number of community projects that could have partnered with the NRP

project to facilitate policy reforms and implement practical projects in the mental health field. The

NRP partnerships are facilitating planning of the Supporting smoke-free pregnancies among

Aboriginal women and their families project.

LESSONS LEARNED

The NRP project partnerships can enhance very positive connections between partner

organisations and beyond to implement different strategies

It takes some time to build momentum around an issue like smoking and there are competing

demands between the opportunistic options and the planned agenda

Training for health service providers and health promotion staff in motivational interviewing and

brief interventions is extremely worthwhile – a small investment of time and resourcing through

training initiatives can motivate, support and build the confidence of individuals to approach

smoking cessation conversations with their clients in an informed, empathetic and efficacious

way.


44

PROPOSED WAY FORWARD

In relation to the high need for a focus on mental health: work with the mental health sector using

best practice and innovative strategies to support quitting. This could include:

Raising awareness of the importance of the issue, the size of the challenge and the need for

action by the mental health sector. Physical health concerns, including smoking, have played a

back seat to treating mental health problems. Illustrate that people with mental health issues

want to quit and can quit. Quitting smoking improves both mental and physical health in the long

term. Ensure primary care services are included

Inform people about what workers and organisations can and should do to assist clients to quit

(e.g. training, smoke-free policies, encouragement and awareness-raising and a consistent

approach) and how organisations are approaching the challenge (e.g. Minda has recently gone

smoke-free throughout their organisation including residences; Catherine House is increasingly

becoming smoke-free)

Work with organisations such as supported residential care facilities to assist them to change

their policies towards becoming smoke-free and to encourage their residents to quit

Ensure a check on smoking status is built into all intake procedures for relevant health

organisations and build skills of primary mental health workers to help people quit by

undertaking brief interventions for all smokers regardless of whether they want to quit. Primary

Health Network contracts should include quit support.

Progress opportunities for working with NGOs on

smoke-free policies

Look for opportunities to embed smoke-free

policies into all projects and funding

Review recommendations from the Tobacco

Round Table with a small group of

stakeholders/participants and identify priorities.

Objective 1.2 is to increase health literacy about COPD and asthma

The concept of progressive universalism underpinned the NRP. This involved combining universal,

whole-of-community approaches (such as providing information about smoking, asthma and COPD)

with progressively more targeted support for higher need communities. This included the intention

to improve access to health services and prevent and better manage respiratory disease by better

understanding consumer views and then adapting service responses accordingly to make services

more accessible, acceptable and affordable for high need, low literacy individuals and groups.

About 40% of Australians have adequate or higher levels of health literacy, leaving 60% who

require assistance.39

Increasing health literacy activities includes:

1.2.1 Identifying consumer barriers to COPD and asthma preventive behaviour, self-management and preventive service use

1.2.2 Monitor availability and suitability of respiratory information resources (clear, accurate, low literacy, culturally appropriate, availability of services etc.) for consumers in a coordinated way

1.2.3 Delivering awareness events and promotions 1.2.4 Increasing the availability of consumer education sessions/self-management

programs/promotion of helplines.

The National Mental Health

Commission’s Review of Mental Health

Services includes a target to reduce

smoking rates of adults over 18 years

with a mental illness by 30% in 4 years

and 60% in 10 years.


45


Understanding Community Views

A number of strategies have been implemented to gain consumer views on preventing and better

managing respiratory health including self-management. These are outlined below.

In August 2013 the project coordinator met with mental health agency staff who work closely with

consumers. They identified the following issues:

There is minimal awareness of services, information or programs on COPD, asthma or smoking

amongst both consumers and service providers

Limited services to support people with mental illness to quit smoking; quitting is expensive;

need to focus on youth; also need quit training for mental health providers

Lack of awareness and support for mental health issues related to having a chronic disease

The opportunity to promote awareness at community events, e.g. the Carnival in the North – a

‘healthy body / healthy mind’ theme was adopted for the 2013 Carnival held during Mental

Health Week as a result of the NRP consultation.

Breathless in the North

In July 2014 a Respiratory Case Manager for Chronic Disease Management at the Lyell McEwin

Hospital set up a new support group for people living with chronic respiratory conditions – self-

named by its members, ‘Breathless in the North’. This was in response to staff and patients

identifying the need for a support group. The group is open to people with chronic respiratory

conditions, such as emphysema, asthma, or any other obstructive lung condition, as well as those

suffering lung cancer, interstitial lung disease or other restrictive lung conditions. Relatives and

carers of patients are also welcome to attend. Despite poor health experienced by many,

participation is good with around 12-15 people meeting monthly at a local community centre in the

Playford area; around seven meetings have been held to date. The facilitator is arranging speakers

on topics of interest to the group, and the NRP project coordinator has been invited to present in

2015 (see Box 4.3).

Box 4.3 ‘Breathless in the North’

“We know that support groups are an opportunity for people with similar experiences to come

together, support and learn from one another and also develop knowledge that can help them to

manage their condition and hopefully lead to better health outcomes.”

“We hope that a support group will be one way for people to better deal with and self-

manage their chronic lung problems and help them to perhaps not feel a sense of isolation.”

Alan Ashenden, Respiratory Case Manager for Chronic Disease Management at Lyell McEwin

Hospital

Respiratory support group member said:

“When you have emphysema you can’t do much because it really restricts you, so this is a

chance to have a social outing and talk with people who are going through the same thing,”

“It’s also a good opportunity to learn more, because you realise that you think you know a

lot about the condition but there’s also a lot you don’t know.”


46

Asthma SA ‘Ask the Expert’ Consumer Forum

In order to specifically engage parents/carers of children with asthma and allergy, an ‘Ask the

Expert’ consumer forum was held during the first week in September 2014 – National Asthma

Week. This event comprised three experts, a Paediatric Respiratory Specialist, an

Immunologist/Allergist, and a Paediatric Clinical Practice Consultant who works in the Lyell McEwin

Hospital Emergency Department. The event covered childhood asthma, childhood allergy and what

happens in an emergency department when a child presents with asthma symptoms. Attendees

were also invited to ask questions during the session. Approximately half the attendees registered

for Asthma Assist Services, which means they are sent an Asthma Control Pack and kept informed

of Asthma SA news via newsletters, asthma updates and social media. The event was attended by

42 parents/carers.

Evaluation of the forum showed:

35% of attendees reported that their children had asthma, 6% had allergies, and 23% reported

both

90% of the parents/carers who attended either agreed or strongly agreed that the event was

worthwhile.

Attendees identified that the most challenging aspects for caring for a child with asthma/allergy were

managing triggers, finding a GP with an interest in asthma, and lack of confidence in asthma/allergy

management. This information was considered in the decision to support establishment of general

practice respiratory clinics and will continue to inform asthma initiatives involving GPs, practice

nurses and pharmacists in the NAML region.

“What a great idea, thank you for taking the time for having us.”

“I had thought I was being over cautious, however, now I know more about asthma I will be

proactive in pursuing preventers.”

“I will take more time with my GP to discuss specific questions and request a referral if

needed.”

– Comments from people attending the ‘Ask the Expert’ consumer forum

Community consultation on COPD

In December 2014 NAML sponsored a community engagement workshop for people living with

COPD, and their carers, to gather local consumer views on the experiences of living with COPD in

the NAML and wider Adelaide metropolitan region – i.e. to understand the perceived barriers,

irritants/frustrations and supports that exist, and to recommend service responses based on these

insights. Thirteen consumers and carers attended and there was active participation. This was part

of NAML’s broader community engagement agenda to gather local consumer views on experiences

of living with a chronic condition(s) and accessing health services in the NAML and wider Adelaide

metropolitan region.

Analysis of comments made during the consultation showed the following factors as major ‘irritants’

or difficulties in living with COPD. Factors 8, 9, 10 and 11 below make up nearly 60% of the

challenges people faced:

1. Lack of special knowledge of COPD in medical centres

2. Lack of public awareness and education on COPD

3. Physical access to the services is difficult

Figure 7


47

4. Continuity and consistency of care – seeing different professionals every time

5. Uncaring health professionals

6. Difficulties with accessing rehabilitation and exercise services

7. Cost of living with COPD

8. The frustration of not being able to lead a ‘normal’ life

9. Lack of timely and ongoing access to care

10. Lack of awareness and support for mental health issues

11. Lack of information about COPD and services

In terms of opportunities for improvements the consumer group made the following suggestions in

order of importance:

1. Ongoing support for exercise and rehabilitation

2. Affordable care and services

3. Ready access to help, support and advice in relation to COPD

4. Consistently seeing the same health professional(s)

5. Caring empathetic staff who treat me as an individual

6. Treating the ‘whole’ person

7. Physical access that caters for COPD-specific needs (e.g. no stairs, parking near to the

door)

8. Greater community awareness and support in relation to COPD

SUMMARY

The performance and outcome measures relating to this objective were:

Consultation measures have been implemented and reported; and

Strategies used have enabled participation by groups where literacy levels and access to

services would usually exclude participation.

Several types of consultations were held (rather later than earlier in the project) and provided useful

information. Throughout the project consumer views were also collected in an ad hoc way and

information on consumer knowledge, attitudes and behaviours was gleaned from all project

strategies. Partners with strong ties to consumers, including Lung Foundation Australia and Asthma

SA, provided ongoing input on consumer perspectives.

LESSONS LEARNED

Experience elsewhere suggests that consumers are interested in participating in consultations

on respiratory health.40 The NRP experience was that consumer forums can take a lot of time in

encouraging people to attend.

If possible, identify a mechanism to obtain consumer input progressively to inform initiatives.

Ensure all activities have sufficient lead-in time to allow for proper consideration/input by the

relevant project partners; this is also important for keeping the relationship strong and so

partners feel valued.


The views of parents of children with asthma provide valuable information for the future, as do the

insights gained from the COPD workshop – use these to inform future project and service planning.

The proposed Adelaide Primary Health Network ‘Consumer and Carers’ Membership Consortium

Group could also serve to act as a sounding board for initiatives. Approach other health consumer

organisations for support and participation. Draw on current research literature on consumer views

regarding respiratory health and recommended service responses based on consumer insights.


48

Respiratory resources for consumers

Underpinning this activity was the recognition of multiple sources of information made available to

consumers from health services, NGOs, pharmaceutical companies, etc. and the potential for

confusion and conflicting information, as well as the possibility that there were gaps in availability of

low literacy and culturally appropriate resources.

Although an initial stocktake of consumer resources was completed, subsequent action was rather

more opportunistic than systematic. The NRP consistently promoted the resources prepared by

Asthma SA, the Lung Foundation Australia, Quitline and DASSA. These resources were distributed

to relevant primary health care providers and used at community events. Information on service

availability has also been promoted, e.g. the Quitline, Asthma Assist Services, etc. The

comprehensive COPD and asthma resource packs provided to the general practice respiratory

clinics (whose establishment was supported by the NRP) were primarily made up of these

resources. A more coordinated approach to respiratory resources evolved amongst the partners as

the project progressed. For example, Quitline and NALHN now have a process by which resources

can be distributed across the LHN and reordered, while Asthma SA also now make Quitline

resources available at their community event stalls. NAML too is actively promoting Asthma SA,

Lung Foundation Australia, DASSA and Quitline resources, where relevant, at community events

that their health promotion and/or clinical staff attend.

There has been promotion of smoking-cessation-related resources for Aboriginal people but more

could be done in relation to reviewing, promoting and distributing culturally appropriate resources

about respiratory conditions.

Raising community awareness

Respiratory health was promoted at a number of community events throughout the project.

Examples include:

City of Playford Health Expos in May 2014 and 2015 (see photo below); Asthma SA attended

both events. NAML also attended the 2015 event and made the Lung Health Checklist available

to community members who were interested

Gawler Show in August 2014

As part of the smoking survey NAML staff promoted respiratory health (e.g. Quitline brochures)

at various shopping centres in the Playford/Salisbury region.

NAML’s CALD/Refugee Health Project Coordinator distributed Spanish-language quit smoking

information at the Spanish Cancer Prevention Forum in May 2015, e.g. ‘Stopping smoking is the

only healthy option’ fact sheet – in Spanish.


49

The intention to develop examples of good practice and innovative, universal and targeted

community awareness activities and information was not achieved.

Consumer support

Lung Foundation Australia held their annual Lung Health Education Day for consumers in Adelaide

on 30 October 2014. NAML supported the event by assisting with promotion through general

practices in our region and holding a display stall at the event on the day. The NAML CTG team

promoted the event to all clients with chronic respiratory conditions, with an offer to provide

transport assistance and cover the registration costs. A small number of CTG clients attended, as

well as two Aboriginal Outreach Workers from NAML, the NRP project coordinator, and a practice

nurse from the NAML region. Attendees were pleased to receive information directly from experts

on the topics of safe use of medicines, understanding Cochrane reviews and stem cell research.

Six pharmacies in the NAML region held an event to recognise World COPD Day in November

2014, raising awareness about COPD, the need to manage the condition in partnership with a

doctor, importance of having a COPD action plan and using inhalers properly, amongst other

information. This is discussed further in chapter 5.

Smoking cessation promotions have been covered in section 1.1.4.

Both the Asthma Assist infoline and the Lung Foundation Information and Patient Support line were

promoted to service providers and consumers whenever possible. Results from the Asthma

Pharmacy Referral Pathway (APRP) program (see chapter 5) show clearly that telephone helplines

can assist people with respiratory conditions to manage their illness. Results reveal a significant

increase in calls to the Asthma Assist infoline from NAML residents. This does not include the initial

calls made as part of the APRP and is a pleasing result.

Calls to the Asthma SA Asthma Assist line have risen from 78 calls January-June 2012 to 178

calls in the six months to April 2015

SUMMARY

This was a multi-component area. Helplines were promoted at every opportunity and the increase in

calls to the Asthma Assist infoline is a very positive result. Consumer views were collected in a

variety ways including through the smoking survey, asthma session with experts and through

discussions with people with COPD, and these were fed into education sessions with health care

providers. Consumer education occurred through events such as World COPD Day. These were

positive outcomes. Self-management was supported through the Breathless in the North group.

LESSONS LEARNED

Consumer consultation should occur as early as possible in a project or program such as

this, ideally at the project planning stage to best inform directions

Consumer/community consultation does not always need to occur at formal events held with

this sole purpose in mind – useful information can be gathered opportunistically through

written surveys or as an add-on to event evaluation feedback forms at any forums/events

where consumers and communities may be present


Support the early plans to engage children and their families in managing asthma through

innovative means, building on the NRP partnership. Look for different opportunities to support


50

self-management, e.g. through pulmonary rehabilitation programs. Continuously identify and pursue

opportunities to gain insights into local consumers’ experiences and perceptions of living with, and

managing, their respiratory condition.

Objective 1.3 is reduce risk conditions for COPD and asthma through community settings

Reducing risk conditions activities include:

1.3.1 Deliver education interventions in key settings (child care, schools)

1.3.2 Explore options to undertake training in workplaces, aged care and sporting clubs

1.3.3 Defining and supporting respiratory-friendly practices and programs in partnership with local

government (6)


Asthma-friendly schools

Asthma affects around 1 in 10 children and children from families with low socio-economic status

have higher prevalence of asthma, with this gap increasing. One in 12 children with asthma are

exposed to tobacco smoke in their home.41 Among those aged 0-14 years, current asthma is more

common in males than females, but among those aged 15 years and over, the reverse is true.42

Hospital separations and ED attendances are also higher for low SES, Aboriginal and culturally and

linguistically diverse (CALD) groups. Asthma admissions increase when children return to school

especially after the long summer break. Poor asthma control (frequent symptoms and flare-ups) in

children (and adults) is a common problem; asthma is a leading cause of absenteeism in school

students.43 For young people (aged 12 to 25 years) 42% reported that they had missed school,

work, or university in the past 12 months due to asthma.44

Children spend considerable time in educational and other settings so increasing the knowledge of

staff and parents/carers about asthma generally and asthma in children, as well as their ability to be

proactive in assisting children and responding to asthma is important. It is recommended that all

children with asthma have an Asthma Action Plan and that a copy is lodged with the education

setting; settings are also required to have an Asthma Emergency Kit. The reduction in childhood

deaths is at least partly attributable to a proactive approach from education settings towards the

management of asthma.

Preschools (primarily 4 year olds) are required under legislation to have staff trained in asthma

management. Schools in SA can choose to become ‘Asthma Friendly’ once trained – this requires

education and training of staff; availability of AEKs; provision of information on asthma and policies,

i.e. first aid and other health and safety policies must explicitly include asthma.

The NRP initiative provided funding to Asthma SA to increase the number of education and other

settings trained in the NAML region, ensuring settings support better asthma management. The

results are set out in Box 4.4 and all targets were achieved.

Box 4.4 Asthma SA Case Study: NRP school and children’s service initiative

The aim of this initiative was to reduce risk conditions through the provision of asthma first aid

training in 80% of primary and secondary schools, as well as children’s services, in three priority

areas in the NAML region (Playford Elizabeth, Playford West Central and Salisbury Central). This

training program is an evidence-based approach implemented throughout Australia45 and run locally

in South Australia by Asthma SA.


51

The total number of schools and children’s services reached in the NRP priority areas included six

primary schools, three secondary schools, and five children’s services. With a result of 74% of sites

being trained in the three priority locations, the performance target was almost met and represented

a 24% increase from a baseline of 50%. The target of a 20% increase in asthma first aid training in

the non-priority locations was slightly exceeded.

Between the baseline date of 1 May 2013 and 31 December 2014 an additional 36 primary schools,

19 secondary schools, and 24 children’s services in the NAML region (but outside of the priority

areas) completed asthma first aid training. The total number of schools and children’s services

reached in the NAML region (priority and non-priority areas) as part of the NRP equates to 42

primary schools, 22 secondary schools, and 29 children’s services, totalling 93 sites. Asthma SA

considers this to be an outstanding result. Details are provided in Table 4.4.

At the beginning of the initiative contact was made with a list of priority schools and children’s

services in the NAML region to determine their training and Asthma Friendly status. All sites in the

priority areas were sent a letter, co-signed by the Regional Director, Department for Education and

Child Development and the NAML Chief Executive Officer, outlining the project and offering training.

In addition, Asthma SA Schools and Children’s Services Coordinators visited ten sites in the priority

areas identified as not ever having participated in training.

Table 4.4 Education sites in the priority areas in the NAML region with current asthma first

aid training across the intervention period (May 2013-Dec 2014)

Measure Primary Schools

Secondary Schools

Children’s Services

Total

Total number of sites in NAML region

111 38 197 346

Number of sites in priority locations

21 6 31 58 (16.7%)

Number of sites in priority locations with current training at baseline – 1 May 2013

10 (47%) 1 (16%) 18 (58%) 29 (50%)

Number of sites with current training in priority locations at 31 December 2014

16 (76%) 4 (67%) 23 (74%) 43 (74%)

Number of sites that received training in NAML region between 1 May 2013 and 31 December 2014, but outside of priority areas

36 (32%) 19 (50%) 24 (12%) 79 (23%)

It should be noted that some sites required extensive promotion via post, email, telephone and face-

to-face contact before embracing the training opportunities available. In particular, a small number

of sites in the priority areas proved very difficult to engage.

Through the NRP, Asthma SA used its school networks to also engage students and

parents/carers. This engagement focused on increasing awareness of asthma and asthma self-

management skills.

At each training session the level of participant confidence and knowledge was evaluated pre- and

post-education. Although participants felt reasonably knowledgeable and confident about asthma

and managing an asthma flare-up pre-education, their knowledge and confidence were increased

as a result of the training (see Table 4.5).


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Table 4.5 Evaluation of participant knowledge and confidence following asthma first aid

training

Evaluation measure Pre-education (score out of 5)

Post-education (score out of 5)

Confidence to recognise asthma signs and symptoms

4.2 4.8

Knowledge of asthma first aid procedure 4.1 4.9

Confidence to manage an asthma flare-up 3.9 4.7

Supportive workplaces and community organisations

Whilst objective 1.2.1 covers education settings and thus children, this action sought to better reach

adults through workplaces or potentially sporting clubs or other community facilities. The intention

was to assist workplaces to recognise and respond to an asthma flare-up in the workplace, as well

as raising awareness of the impact of chronic conditions on productivity and worker health.

The industries of interest were identified as either those with higher rates of smoking, which are

difficult to identify, and those where there are triggers for poor respiratory health in the workplace,

i.e. people employed in the plastics, rubber and chemical industries, nurses, timber workers and

welders, and jobs involving painting (particularly spray painting), dyeing, cleaning, baking and food

processing, farming, occupational fumes and dusts, laboratory work, exposure to biomass fuels and

working with animals.46

This proved challenging. Asthma SA have found it very difficult to engage workplaces in asthma first

aid training, reducing their staff allocation of time to workplaces due to lack of uptake. An approach

was made to the Healthy Workers – Healthy Futures initiative however this was not progressed due

to staff turnover.

After discussion with the PMC it was agreed that the focus would be on inviting residential aged

care facilities (RACFs) to receive

free respiratory health training to

assist them to manage asthma and

COPD for their residents. Asthma

SA was provided funding to seek

expressions of interest from all

RACFs in the NAML region. Five

workplaces eventually received this

training – four RACFs and one

government workplace. A total of 41

nurses and health/community

workers attended training (see photo

right). This included eight Aboriginal

and Torres Strait Islander Health Workers from a facility in Davoren Park.

Overall, participants reported an improvement in their confidence in recognising signs and

symptoms of asthma, ability to demonstrate asthma first aid and a willingness to change their

behaviour in caring for people living with asthma and COPD. Common behaviour changes identified

were recommending use of a spacer (23%), checking patient technique (22%) and talking to

patients about asthma first aid (21%) – see figure 4.2.


53

Figure 4.2 Workplace staff confidence post asthma first aid training

Sporting clubs were not approached although work is underway through Asthma SA with key

sporting agencies.

This is an area for further development but given the limited interest in training and policy reforms by

workplaces this needs to be targeted and done in partnership with other workplace programs.

Local government

As identified in relation to smoking there was no progress with local government due to competing

project demands. The intention was to explore options to support local government to create

respiratory-friendly environments, e.g. dust minimisation, first aid training and awareness of chronic

disease (as well as support for quitting smoking). With the benefit of experience it is unlikely to be a

high priority for local councils and other strategies are considered more likely to be fruitful.

SUMMARY

There was very good progress with education settings in the NAML region, and especially the

priority locations, as a result of the partnership with Asthma SA and the alignment with their work.

Ensuring children will be supported to manage their asthma and/or an asthma event helps prevent

serious problems and hospital attendances. Workplaces were harder to engage despite the fact that

COPD is likely to be impacting on workplace health and productivity, however the aged care sector

response was positive.

LESSONS LEARNED

The NRP partnerships (and outsourcing the responsibility) enabled good reach into education

settings but moving beyond this requires further consideration.

The target of 80% in priority locations was a stretch target for schools, but almost achieved –

attention to asthma is one of competing priorities.

The response of RACFs, and that of their individual staff, to the asthma/COPD update training

was positive – many staff indicated a willingness post-education to change their behaviour in

relation to caring for people living with asthma and COPD


54


Look for opportunities to build training and policy reforms on respiratory health into other settings

where there is some alignment with the issue. Increase efforts around asthma/COPD update

training in RACFs to build staff confidence and efficacy in managing these conditions – this has the

potential to have a direct impact on reducing ambulance transfers and potentially preventable ED

presentations and hospital admissions of residents from these facilities.


55

CHAPTER 5 OBJECTIVE 2 SECONDARY PREVENTION

Objective 2 is based on the understanding that many people already have asthma and/or COPD but a number will not yet have received a diagnosis and others will not be receiving best practice management. Good management can slow the progression of the disease and contribute to fewer exacerbations. This was a significant focus for the project with active participation by partners.

Objective 2 To reduce or stop further damage from COPD and asthma through increased early identification and effective management of COPD and asthma for all residents and particularly those areas/groups most at risk

Obj 2.1 Provide information, advice and support to primary care providers

Obj 2.2 Provide intensive support for practices and services in priority areas

Obj 2.3 Identify training needs, options available and promote and support training for primary care practitioners

Obj 2.4 Contribute advice on gaps in COPD and asthma secondary prevention services/workforce and options to meet these needs

Obj 2.5 Contribute consumer views regarding COPD and asthma prevention where possible to inform good practice care (see 1.2 above)

There were a series of detailed actions for each of the sub-objectives as follows. Secondary prevention activities identified for objectives 2.1 and 2.2 were: 2.1 Provide information, advice and support to primary care providers – beginning with

pharmacies and general practice but including NGOs, allied health, AHWs – on good practice for care of people at risk of and with COPD and asthma and wishing to quit. This includes:

Best practice technical guidelines

Practice tools information e.g. register systems, IT

Information on specific service components (e.g. spirometry testing, home oxygen, pulmonary rehabilitation, etc.)

Referral pathway guidelines (including proposed specialist multidisciplinary respiratory service, home care supports etc.)

Funding models

Roles and contributions of different players e.g. GPs, practice nurses, pharmacy, allied health/rehab/physical activity programs, NGO support services, nurse led clinics

Management of specific conditions e.g. asthma during pregnancy, managing those with mental illness and respiratory conditions, managing co-morbidity

Prevention information including brief interventions 2.2 Provide intensive support for practices and services in priority locations to implement

changes in line with guidelines and identify opportunities and barriers to improving services for those with high needs


56


Objectives 2.1 and 2.2 are considered together as they are interrelated. Pharmacies and general practices were the main focus. To inform the work a list of all general practices and pharmacies was prepared and those located in the three priority areas (see chapter 3) identified. Table 5.1 summarises the results. Table 5.1 Number of general practices and pharmacies in the NAML region and priority locations

Provider Number in the NAML region

Number in the priority locations

% of total in priority locations

General practices 93 29 31.2%

Pharmacies 83 22 26.5%

Pharmacy Intervention Pharmacies were an initial focus of attention with Asthma SA, PSA, Lung Foundation Australia and NAML working in collaboration. Pharmacies are well placed to assist people with effective use of medication which is a key part of managing both asthma and COPD – see Box 5.1. Both Asthma SA and Lung Foundation Australia have a history of working with pharmacies on respiratory health and the PSA was able to provide extensive expertise on the needs of community pharmacies, the best approach to working with them and strategies currently in place. Box 5.1 Pharmacies have a key role in respiratory health Pharmacists are key partners in a comprehensive approach to respiratory prevention and care.47,48 Their extensive clinical knowledge around medications and devices, combined with their access in the community (in some cases 24 hours a day, 7 days a week) and the regularity of their interaction with consumers, makes them uniquely capable of helping those with chronic respiratory conditions.49 Pharmacists can play a role in:

Checking patients’ use of inhaler devices - Australian asthma research suggests 90% of people use their devices incorrectly.50

Providing information on COPD and asthma medications - managing medications is an important issue for consumers who may be required to take a number of medications.51 In 2008-09, 50% of asthma expenditure nationally was on prescription pharmaceuticals52; the figure was 23% for COPD expenditure in the same year.53

Providing advice on quitting smoking – trained community pharmacists can deliver cessation interventions and help smokers to quit, and counselling programs delivered in this setting can be effective though follow-up is required.54

In a community pharmacy COPD case-finding service in England, 135 patients (56.7% of those screened) were identified with potentially undiagnosed COPD indicating the importance of case finding. Of these, 88 were smokers. Smoking cessation initiation provided a project gain of 38.62 life years, 19.92 quality-adjusted life years and a cost saving of £392.67 per patient screened.55

Training can be effective in building knowledge and skills:

Evaluation of a Lung Foundation Australia COPD Risk Assessment and Screening workshop for pharmacists showed improved scores in identifying customers at risk, undertaking a risk


57

assessment, checking for contraindications, conducting a PiKo-6 test, and planning for and implementing a COPD risk assessment and screening service.56

The evaluation of the Lung Foundation Australia COPD pharmacy online training showed knowledge increased in relation to all six questions (e.g. role of the pharmacist, importance of vaccination and PR, seriousness of COPD, etc.), as did confidence in relation to 14 items including: conducting a case-finding test using a PiKo-6 or COPD-6 device and undertaking a risk assessment using Lung Foundation Australia’s Lung Health Checklist.57

The Quality Care Pharmacy Program includes three areas related to this intervention that makes it relevant to key pharmacy directions: health promotion; risk assessment and screening; and disease-state management. The aims of the pharmacy intervention were: Universal – all pharmacies: support all non-priority area NAML pharmacies to implement evidence-based management for COPD, asthma and smoking cessation through:

Informing them about the project, aims, objectives and key strategies

Seeking their views via a survey on key issues

Continuously advising on training that is available for pharmacists and assistants (see objective 2.3)

Providing advice on where to refer (Asthma Assist Services, Lung Foundation Australia Information and Patient Support, Quitline)

Providing information on the resources available from Asthma Assist Services, Lung Foundation Australia, Quitline and Quality Care Pharmacy Program (QCPP)

Seeking potential champions and interest in attending a discussion on respiratory health. All non-priority area pharmacies (53) were sent the above as well as a survey seeking ideas and information. There was only one response to the survey. Targeted – pharmacies in priority locations: intervene with pharmacies in priority locations (N=22 i.e. 10 in Elizabeth; 4 in Playford West Central; 8 in Salisbury Central; plus 8 more adjacent to these areas) for six months – three months with an asthma focus (January-April 2014); three months with a COPD focus (April-July 2014). Review and repeat and expand, subject to success and participation rates. Targeted approach Phase 1 Asthma – Pharmacies Phase 1 was related to asthma as COPD required stronger collaboration with GPs given the issue of screening and referral; the results are summarised in Box 5.2. Eight pharmacies agreed to participate in the respiratory initiative. Seven (87.5%) of these were in or very near to the priority locations (23% of 30 pharmacies). The referral form to Asthma SA is at Appendix 4. To enhance the evaluation, the intention was to send a ‘mystery shopper’ into participating pharmacies to check their level of service provided for people with asthma. This was not progressed as advice was provided by the PSA that individual pharmacies should approve this strategy and most did not. A consultant pharmacist was engaged by the PSA to assess the eligibility of pharmacists for Continuing Professional Development (CPD) credits. Participants selected a number of methods to address their learning needs in identified areas. These included attending training sessions, self-directed learning and the presentation of information to other pharmacists and pharmacy staff. Each pharmacist was provided with a one- to two-page report for their own CPD records, confirming their attainment of Group 3 CPD credits. Results are shown in Table 5.2.


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Table 5.2 Pharmacy continuing professional development credits assigned for the asthma initiative

Pharmacy Group 3 credits assigned to individual pharmacists*

1 31.5

2 16.5 & 10.5

3 16.5

4 12.0

5 16.5 & 6.0

6 7.5

7 9.0

8 13.5 & 13.5

* NB: Two sets of credits shown for one pharmacy indicates that two pharmacists were assigned credits Box 5.2 Case Study: Asthma Pharmacy Referral Pathway (APRP) program The aim of the APRP Program was to increase early identification and effective management of asthma through a referral pathway to Asthma SA from eight participating pharmacies located in the Northern Adelaide Medicare Local (NAML) region. At the commencement of the APRP Program the pharmacies were invited to attend an information session. Nineteen participants were provided with an introduction to the program and provided with resources including referral forms and Asthma Control Packs supporting implementation in the pharmacy setting. Ninety-five percent surveyed at the end of the evening indicated that the session was ‘entirely relevant’ to their practice (other response options ‘partially relevant’ and ‘not relevant’). The referral pathway is described below.

A total of 165 referrals were received via the eight participating pharmacies. Of these, 68.4% (113) were either fully completed (initial and follow-up education) or had an initial education session only completed. Regardless of the outcome of the referral, a letter was sent to the treating GP (with client


59

consent) outlining the areas for action. The referring pharmacist also received a copy of this letter.

The list of all open actions arising from previous PMC meetings, with status and progress notes, was reviewed (see action list attached) – additional discussion below The following impact measures were assessed at baseline, one month and 12 months post intervention (baseline n=75; one month n=74; 12 months n=48):

Average Asthma Score Asthma Action Plan Spacer Use

An Asthma Control Score was conducted with each client at baseline, one month follow-up and at 12 months. The average score increased from 15.47 at baseline to 18.31 at one month and 21.24 at the 12 month follow-up, moving some clients from poorly controlled to well controlled, some from well controlled to total control, but importantly moving some from poorly controlled to totally controlled. The average score shows a movement from poorly controlled (15) at baseline to well controlled (21) at 12 months.

22% of clients owned an Asthma Action Plan at baseline, this increased to 38% at one month post intervention. At 12 months post intervention 69% of clients owned an Asthma Action Plan.

35% were using a spacer at baseline and this increased to 54% at one month post intervention. At 12 months post intervention, 79% of clients were using a spacer.

GP Review Hospital Visits

At baseline, 54% of clients had a review with their GP and at one month post intervention 62% had a GP review. This increased to 81% when including those who intended to see their GP for an asthma review. At 12 months post intervention 85% had seen their GP for a review.

At baseline 30% of clients had visited the hospital in the last 12 months because of their asthma, with 15 people having had a total of 22 hospital visits between them:

10 clients had 1 hospital visit 2 clients had 3 visits 3 clients had 2 visits 59 clients had not visited a hospital in the preceding 12 months pre-intervention. NB: ‘hospital visit’ = admission or ED presentation

At one month post-intervention 3% of clients had visited the hospital due to their asthma in that one-month period

Of those who had 1 hospital visit each, only 1 had re-visited hospital

Of those who had 2 hospital visits at baseline, only 1 re-visited hospital

Of those who had 3 visits at baseline, none had re-visited hospital

Of the 59 clients who had not visited hospital prior to the intervention, none had visited hospital in the 12 months post-intervention

At 12 months post-intervention only 2 clients (6%) had visited hospital due to their asthma.


60

Overall, feedback from the pharmacies was extremely positive. A survey and some site visits were conducted. The results demonstrate that they agreed or strongly agreed that participating in the APRP Program was worthwhile, highlighting many benefits to their clients and their pharmacy practice including their ability to target clients with asthma who were most at risk. The most common barriers pharmacists found were that customers did not have time to complete the form, they did not provide consent, the clients felt they had enough asthma information and that pharmacy staff were too busy to make the referral. Asthma Educator during phone consultations with pharmacy referral clients

Targeted approach Phase 2 COPD – Pharmacies

Phase 2 involved working with the same pharmacies to achieve the following:

Upskill pharmacists and pharmacy assistants in target locations in COPD therapeutics,

management and patient care

Promote community awareness of key COPD management areas such as inhaler technique,

COPD Action Plans, treatment adherence and smoking cessation

Increase health literacy around COPD in patients who attend pharmacies

Model a collaborative approach between pharmacies, GPs and respiratory physicians.

The Lung Foundation Australia played a lead role in this phase of the pharmacy initiative, with

support from NAML. Each participating pharmacy was provided one enrolment access to Lung

Foundation Australia’s COPD Pharmacy Training and support program that included:

COPD Pharmacy Online Training

PiKo-6 device starter pack

Pharmacy in-store collateral (including Lung Health Checklist, posters, flyers, shelf-talkers and

balloons)

Access to a webinar: Implement a COPD Service in Pharmacy

COPD screening results forms for those without Guildcare software.


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Seven of the original eight pharmacies participated in the COPD phase, with six of these operating

in priority locations. The NRP provided a PiKo-6 starter kit to allow pharmacies to trial a COPD

screening service in-store. Three pharmacists joined general practice staff for the Implementing

COPD Risk Assessment and Screening in Pharmacy workshop in June 2014 conducted by Lung

Foundation Australia and NAML. This covered use of Lung Health Checklist and PiKo-6 device.

Lung Foundation Australia also delivered this training in-pharmacy to 14 pharmacy staff from five of

the participating pharmacies for those who could not attend the workshop. The original intention had

been to have this delivered by an Adelaide-based GP and community pharmacist but this proved

difficult to arrange.

One of the NRP partners raised the potential issue of general practice concern in relation to

pharmacists undertaking PiKo-6 screening. The Northern Region GP Council reviewed the issue

and suggested all practices be informed of the training of pharmacists and the need to work

together. A letter was sent to GPs, following review by the NRGPC representative on the NRP

Project Management Committee and no issues were raised by GPs.

Pharmacists in two of the eight pharmacies did not progress with the COPD online training and

hence their training places were offered to pharmacists from other pharmacies in the NAML region

where an interest in COPD screening had been shown. It was noted that both of these pharmacists

completed the online training very promptly and expressed an interest in being involved in any

future respiratory initiatives. At the close of the project four pharmacists had completed the training,

one was very close to completion and another three were underway. All who completed the training

remarked that they found it very valuable. It did require a significant time investment and in order to

complete most did it in their own time away from their busy pharmacy work – in some cases multiple

reminders were required to encourage completion. Reminders about the CPD credits attached to

the training (eight hours of Group 2 CPD, or 16 CPD credits) were given to incentivise completion.

All of the pharmacies that had been involved in NRP initiatives were encouraged to hold an event

for World COPD Day on 19th November 2014 – this was a good opportunity to talk with customers

about their lung health and build their confidence with screening. All participating pharmacies were

visited by Lung Foundation Australia or the NRP Project Coordinator ahead of the day – Lung

Foundation Australia provided free resource packs to support their event and the NRP sponsored

promotional T-shirts for staff to wear. Five community pharmacies held a COPD screening activity

on World COPD Day in the NAML region in 2014; this was one seventh of the total across Australia

that ran such an event. Another pharmacy encouraged customers to complete the Lung Health

Checklist on their Healthpoint touch screens.

In terms of impact, the following was achieved:

17 pharmacy staff were trained in administering the Lung Health Checklist, using the PiKo-6

device and provided information about COPD; the number of COPD screens undertaken has

been difficult to gauge because pharmacists have either completed forms in hard copy and

given the results to customers without keeping a record or have not accessed the electronic

data from their software for reporting purposes

Consumer resources were distributed to eight pharmacies and there was community

awareness-raising and advice provided by these pharmacies

Five pharmacists have undertaken comprehensive COPD online training.

Participating pharmacists were surveyed to gauge their opinion of the value of participating in the

NRP – see Box 5.3.


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Box 5.3 Survey of pharmacies participating in the NRP

Seven of the eight participating pharmacists were phoned by PSA (SA/NT Branch) to participate in a brief

phone survey about their views of the NRP. All had participated in one of the pharmacy-related education

sessions or initiatives. A series of questions were asked which related to motivations for being part of the

NRP project, reflections on the training and future training needs, behaviour change, relevance,

sustainability and NAML support.

The respiratory focus was agreed to be highly relevant to the northern Adelaide demographic, given the

region’s lower socio-economic status, lower health literacy and higher smoking prevalence rates.

Reasons for participation in the NRP initiatives included: the desire for pharmacists to have a greater role

in assisting patients improve their health outcomes; the belief that there is a need for greater education in

the northern Adelaide demographic with regards to respiratory disease; the potential for multi-disciplinary

care; and an opportunity to incorporate the initiatives into the Fifth Community Pharmacy Agreement

(5CPA) Pharmacy Practice Incentive programs to enhance patient care.

Changes to practice included: a greater engagement with patients both at the contemplation phase of

quitting smoking and during their smoking cessation therapy (e.g. with varenicline or nicotine replacement

therapy); increased involvement of pharmacy support staff within the over-the-counter smoking cessation

section of the pharmacy; offering Quitline handouts and proactively referring to relevant support services –

i.e. Quitline or Asthma SA. These activities were mostly considered to be ongoing and the benefits derived

for patients and the pharmacy business sustainable.

Enablers for implementing positive changes in practice included: a private consultation area in the

pharmacy; support given by NRP; and the enhanced confidence of pharmacists in approaching and

counselling patients. Attendance rates at workshops, and interest overall, were encouraged by

accreditation of activities. Where possible, PSA attached Group 2 CPD credits; some pharmacists

confirmed that Group 2 credits were more desirable than Group 1.

Limitations included: time constraints of the patients; skilled staff moving onto different jobs; insufficient

resources to go forward; and the resistance of patients to provide personal details to a third party – e.g.

referral to Asthma SA. A number commented that the PiKo-6 training was useful but may not be

sustainably implemented in practice due to time restraints, limited trained staff, and the fact that most

initial diagnoses occur within GP clinics.

The educational quality of the motivational interviewing, asthma, and smoking cessation training sessions

were viewed as useful. All pharmacists commented that they enjoyed the training and achieved some

benefit from the sessions.

The pharmacists interviewed agreed that the support offered by NAML on behalf of the NRP during the

asthma and COPD phase was of a good standard. Some pharmacists mentioned they appreciated the

feedback letters which informed them of their progress, as well as the in-store visits.

Future training needs identified include:

a focus on older people

more depth on the technical aspects of respiratory devices

ways in which pharmacist involvement in respiratory health can be increased.

Pharmacists would be keen to see more information and opportunities for pharmacy included in NAML

communications. One pharmacist commented that while the public views pharmacies as “first-line care”,

other professional bodies are under-utilising pharmacists’ skills and services.

In summary, the key theme raised was that the NRP initiatives were welcomed and of value, and most

interviewed would like to be involved in future activities.


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General practice intervention

General practice is key to early identification and effective management of both asthma and COPD,

with 85% of people visiting a GP every year.58 The revised Australian Asthma Handbook was

released in 201459 and a COPD-X concise guide for primary care in the same year.60 GPs also

frequently see people who smoke and the relevant guidelines were also updated in 2014.61

GP consultations

To inform the development of this intervention, the NRP conducted a consultation evening with GPs

and other general practice staff in October 2013. Twelve GPs and 18 practice nurses attended; 10

people registered who did not attend. Professor Peter Frith, a leading Adelaide respiratory

physician, presented on the COPD-X guidelines (the Australian and New Zealand Guidelines for the

management of COPD) to provide a platform for the consultation. The Asthma SA PMC

representative presented on the NRP while the GP representative on the PMC facilitated the

consultation session.

Participants in the consultation evening provided the following answers to these discussion

questions:

What would help your practice to support prevention and better management of smoking,

asthma and COPD? Responses included: training staff in the management of clients; data

mining and data cleansing; use of the PiKo-6 and COPD-6; and training of nurses and practice

managers in particular.

What are the barriers to consumers managing their asthma/COPD? Responses included: lack

of knowledge of their own condition and self-denial (and the need to empower patients to take

charge of their own conditions); incorrect use of devices; lack of follow up by patients on

treatment; and low awareness of PR. Participants commented that information about respiratory

conditions needs to be explained to patients progressively, rather than in one go.

What are the barriers to people quitting? Do you refer to the Quitline? Responses included that

the Quitline is not a 24-hour service (though acknowledged that it does automatically record for

follow up calls the following day) and poor awareness of service options exist.

What incentives might encourage your practice to participate in the NRP project? Responses

included: promotion of primary health and smoking cessation as part of a broader suite of

preventable health measures; making GPs passionate about respiratory health and raising

awareness of asthma and COPD action plans and guidelines.

Why are people using Emergency Departments? How could this change? Responses included:

better management of patients’ conditions in general practice; asthma clinics and better

education about hayfever awareness. The cost of medications was also raised as a barrier to

good management.

All of these smoking- and respiratory-illness-related suggestions have been pursued with general

practices actively involved in the NRP.

Consultations with representatives from general practice revealed concern that patients do not

understand their respiratory condition well. One option identified was to link with mental health

services to help patients with motivation and cognitive behavioural therapy and help people manage

the anxiety experienced when not able to breathe well. Subsequently the NAML e-newsletter

included information on the NAML Living Well with Serious Illness program for people living with

progressive life-limiting illness (including asthma and COPD) and experiencing anxiety or

depression. Those eligible for the program are able to access up to 12 therapeutic counselling

sessions at no cost provided they have a mental health treatment plan.


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There has been regular liaison with the Northern Region GP Council (NRGPC) via the NRP Project

Management Committee GP representative. Feedback was sought from the Council on a number of

initiatives targeted at general practices in the NAML region and input/advice was extremely valuable

in shaping the initiatives and tailoring communications to maximise GP engagement. The GP

representative also provided a GP perspective through comments on documents (produced through

the project) and discussions at the PMC. Additionally, participation in the Hospital Working Group

meant hospital staff were readily able to consult on issues relating to the acute/primary care

interface.

The approach – general practice

Originally the intention was to provide intensive support to 90% of practices in the priority locations

(29 practices) with a more general offering to those beyond the three priority areas. This included

employing a part-time nurse who would work in practices (and with pharmacies) advising on

evidence-based practice, assisting with client information systems and referral links and other

support activities. It became clear from the pharmacy response that the 90% target was unrealistic

and this was changed to 40%. Further, recruitment of a suitable nurse for this role proved difficult.

Instead NAML allocated the time of a number of existing staff to NRP work including the Quality

Improvement Partnership (QIP) project (below), advice on the nurse-led respiratory clinics,

assistance with eHealth, etc. The focus then fell into three key areas:

The QIP project on COPD – April to September 2014 – priority areas

Establishment of general practice respiratory clinics – December 2014 to May 2015 – priority

areas

Information to all practices as well as education opportunities – October 2014 (see objective 2.3)

– all practices.

Letter of offer

In early September 2014 all practices in the priority areas were sent a letter from NAML giving

information on the NRP project and inviting them to be involved in some way. Practices were

provided with an information sheet (Appendix 3) with opportunities including:

Expert advice from Asthma SA and Lung Foundation Australia on setting up a respiratory clinic

at their practice

Assistance with developing systems – e.g., to establish registers, implement recalls and General

Practice Management Plans (GPMPs)/Cycle of Care, and to improve outcomes and maximise

potential income streams

Opportunities to access training in respiratory health (with support for priority areas)

Training options, including Lung Foundation Australia’s COPD Nurse Training Online and

Asthma SA’s Spirometry Learning Module for those practices involved in the respiratory clinic

initiative

Up-to-date patient resources delivered to their practice

Links to mental health, PR, end-of-life and other services

In-practice visits – support and advice on respiratory health services such as screening, quit

smoking support and referrals, teaching inhaler technique, etc.

Advice on NAML mental health services

Invitation and support to hold an event on World COPD Day

Promotion of a newly-updated NAML chronic disease referral pathways information booklet,

including a dedicated respiratory section.

Practices that were not in the priority areas received a similar letter in October 2014 but with fewer

(less resource-intensive) options. All letters were reviewed by the NRGPC and the options for


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support were informed by the GP consultation session held in October 2013. There were no major

responses from any practices. Information on the NRP project in general and respiratory health

specifically (e.g. PR availability and efficacy, training opportunities) was provided regularly

throughout the project through the NAML eNews publication.

Australian Primary Care Collaboratives Quality Improvement Partnership project

NAML received Australian Primary Care Collaboratives (APCC) funding through the Improvement

Foundation for the Medicare Local QIP project. This created an opportunity for additional NAML

staff and resourcing to supplement the work of the NRP project, illustrating the extent to which

prevention and better management of respiratory conditions was integrated into the work of NAML.

A side-benefit of this was the upskilling of NAML staff who participated in this initiative, facilitated by

participation in virtually-delivered webinars for Medicare Local staff involved in like projects across

Australia. Another benefit was that the learnings gained through the project were shared with other

NAML practice support staff at their monthly Community of Practice forum, meaning that a wider

group gained a greater understanding of best practice COPD identification and care.

Box 5.4 presents a case study on the initiative and Box 5.5 the results of the initiative in an infographic.

Box 5.4 Case study: A focus on COPD screening, diagnosis and management in general practice In April 2014, NAML recruited seven general practices in the region to be involved in the APCC Medicare Local QIP project, a project supported by the Improvement Foundation. The project ran for six months and its overall aim was to improve identification and management of patients with COPD at selected general practices. A NAML project team used APCC quality improvement tools and principles to support key practice staff through the initiative. They liaised with the NRP project team to ensure that project activities complemented the aims and objectives of the NRP project. In this vein, five of the seven general practices recruited to participate in the project were located in, or very close to, the NRP priority locations. The project team also received strong support from Lung Foundation Australia, including work to increase the respiratory-health-related resources available on the NAML website. The team devised a suite of training to support improved identification and care of patients with COPD through screening, accurate diagnosis and effective management. The package of support included receiving a free PiKo-6 starter kit and comprised a number of formal training/information opportunities:

COPD ‘Priority Workshop’ on 25 March 2014 – information about the project, the Model For Improvement (tool for measuring and testing organisational change) and how this can be applied at the general practice level, and PR options available at the local hospital

Improving COPD Outcomes in General Practice – included use of Lung Health Checklist and PiKo-6 deviceiii, evidence for effectiveness of PR, care planningiv and mental health support for patients with COPD

Full-day spirometry training course. Evaluation feedback in relation to learning outcomes from the workshops was extremely positive with, for example, 100% indicating an increase in confidence in undertaking a COPD risk

iii This session was held at an opportune time to support the NRP’s pharmacy initiative, which was entering its COPD phase – pharmacists were also invited to the morning session, which was relevant to their trialling of an in-store COPD screening service. iv A local practice nurse ran this session and shortly afterwards went on to set up a primary health care nurse network in the NAML region.


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screening and assessment, and 100% feeling increased confidence to perform, understand and implement spirometry. NAML staff also visited the practices to provide data cleansing support and assistance with sending out recall letters. All practices recalled patients aged 35 years and over who smoke to complete the Lung Health Checklist and then, if necessary, the PiKo-6 test and spirometry testing. Up to 300 patients per practice were invited to make an appointment. Lung Foundation Australia’s support of this process and wording of the recall letter was very valuable. Recall letters were found to be a very effective means of encouraging patients to make an appointment – in fact, the practice which had the highest smoking rate of patients with COPD indicated that the patient response to the recall was extremely positive, with a majority of the 300 recalled patients making an appointment. The seven general practices submitted data (data was retrieved via PenCat and manually) to NAML every month. The main results were summarised in an infographic – see Box 5.5. At baseline, few COPD screenings were being done so the goal of increasing the rate of COPD screening by 25% was achieved with a total of 429 COPD screenings performed across the seven practices over a five-month period. Some practice staff also received training from NAML in how to sign-up patients for a Personally Controlled Electronic Health Record (PCEHR), and in viewing and uploading shared health summaries. Three practices held assisted registration days, inviting all patients with a chronic condition to come in to sign up for an eHealth record. This also provided an opportunity to many regular patients of the practices to sign-up for PCEHR, and resulted in more than 80 patients signing up across the practices involved. Finally, all practices were offered the opportunity to participate in the NRP’s general practice respiratory clinic initiative, which commenced shortly after this project wound up. Three went on to do so and, as at May 2015, all three have weekly clinics up and running.


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Box 5.5 Results of the Australian Primary Care Collaboratives Quality Improvement Partnership project on COPD

General practice respiratory clinics project

Support for five general practices in the NAML region to set-up a general practice respiratory clinic

(originally referred to as nurse-led respiratory clinic) was the third major support offered to general

practices as part of the NRP project. A respiratory clinic is one that involves dedicated time (e.g. one

morning per fortnight) for holistic and patient-centred services provided by nurses in collaboration

with a general practitioner. Asthma and COPD were to be the focus of care.


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This initiative arose from the NRP PMC recommendation to build on the work of the QIP project and

support the further growth of practices that had already participated in this rather than spreading the

effort too thinly by working with other practices. The benefits of supporting the set-up of nurse-led

clinics in general practice were identified as:

A chance to further enhance access of people with COPD and asthma to good practice care,

with regular recalls and reminders and to assess the benefits with a view to promoting

expansion if considered valuable

The opportunity for eligible general practices to access Medicare Benefits Schedule (MBS)

funding to support the overall employment of general practice nurses, and also to encourage an

expanded level of practice which may include health promotion, illness prevention and chronic

disease management

Nursing has been recognised for a number of years as one of the most trusted professions by

Australians; clinics can enhance the role of practice nurses and the practice team as a whole

Consumers have indicated that they support health care reforms including nurse clinics, with

84% of those surveyed in an Australian health survey indicating that they would support nurse

clinics.62

There is already one successful asthma clinic operating in the NAML region and others operate

interstate.

The specific aim was to establish patient-centred respiratory clinics in five general practices and

evaluate the model. NAML, Lung Foundation Australia and Asthma SA worked collaboratively on

this initiative.

As stated in Box 5.4, the seven practices involved in the QIP project were approached to

participate. Of these, three agreed. Others in the priority areas were then approached without

success so practices from non-priority areas were considered. The two additional practices chosen

were staffed by nurses who had shown an interest in asthma by attending the NAML education

update on asthma assessment and management run in November 2014. Overall, only two of the

final five were in the priority areas though the other three are also in moderately high risk areas and

their proximity to the two hospital EDs in the region was also considered valuable in terms of

potential partnerships and ED avoidance.

There were four key objectives and progress on each is set out below: 1. Facilitate the establishment of nurse-led respiratory clinics in five general practices

Five practices signed up, having met the minimum requirements (employ or already have a

practice nurse who can lead the initiative; have a spirometer; have appropriate software or be

willing to install it; and a supportive practice manager and GP(s) with an interest in the initiative)

and completed a needs assessment

NAML has visited all practices a number of times to advise on clinical coding, data cleansing

and extraction, assistance with recalls, templates, need for equipment, importance of referring to

Quitline, care planning, clinic trouble-shooting and tips, advice on MBS item numbers, etc.

2. Increase the clinical confidence of respiratory clinic staff in screening, diagnosis and

management of patients with COPD and asthma

This involved two key strategies: firstly, providing access to asthma and COPD resources and

expertise at the clinic and in relation to practical skills, e.g. patient education, spirometry.

Secondly, providing training options: at least one nurse in each practice has completed the Lung

Foundation’s COPD Nurse Training Online; all were to attend the smoking cessation workshop

for general practice (five nurses from three practices participated); and eight completed Asthma

SA’s Spirometry Learning Module and are now submitting their readings for review and

feedback/mentoring from respiratory scientists. One nurse from another practice was also


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invited to do this training, and has completed. One enrolled nurse from a practice that did set up

a respiratory clinic declined to complete the training, and will play only a support role to her

colleague, a registered nurse, who will be running the clinic. All nurses have been offered the

opportunity to attend a further three-hour spirometry update session later in 2015 (optional) and

have been strongly encouraged to register for a full-day asthma and respiratory management

seminar to be run by the National Asthma Council on 20 June 2015, which includes a

component on running a respiratory clinic.

3. Improve the systems capability of the five practices to run the respiratory clinic with a focus on

quality improvement and sustainability

A very detailed information pack was prepared for each clinic including the following information:

o Introduction to nurse-led clinics; benefits to the practice; benefits for GPs; benefits to

patients; barriers and enablers; suggested format/model; resources/equipment required;

MBS item flow charts; templates to import into medical software, including COPD Action

Plan, Quitline referral templates (created by NAML; compatible with four different software);

how to identify patients to invite to attend; data management systems; other smoking

cessation supports and resources (with advice from Quitline and DASSA)

o Asthma section (provided by Asthma SA) – assessment checklists, education checklists,

asthma score template, GPMP template, recall letter templates, Asthma Action Plan

template

o COPD section (much of this was sourced from the Lung Foundation Australia’s online

Primary Care Respiratory Toolkit) – health assessments, risk assessment and screening,

including Lung Health Checklist, diagnosis, evidence-based management, clinical resources

(such as COPD Action Plan) and resources to support self-management (including

electronic versions)

o Additional information – Asthma Management Handbook, COPD-X guidelines, spirometry

resources, Respiratory section of NAML’s Chronic Disease Referral Pathways booklet and a

list of local PR programs and related exercise programs (both available at:

www.naml.com.au/?page_id=2201), and other information identified in the needs

assessment.

In addition, nurses are being supported with the operation of a nurse-led clinic. This includes site

visits and telephone support to nurses as they establish and trial their clinic model, as well as

information on ways to enhance the business model of the practice/clinic in order to improve

business outcomes; assistance with data management and systems; encouragement to

participate in the Practice Nurse Network in the NAML region (only modest success to date);

establishing and building relationships between NRP partner organisations (including local

hospital staff – see objective 3) and providing advice on referral pathways and services available

for patients with COPD and asthma.

It is still intended that a group workshop focusing on the respiratory clinic logistics, simulations,

etc. be held.

4. Increase good practice patient care for those with asthma and COPD attending the nurse-led

clinics

It was intended to monitor a number of measurable indicators including:

o the number of at-risk people receiving a respiratory health assessment

o the number of patients with COPD and asthma with a diagnosis confirmed by spirometry

o the number of respiratory patients with a GPMP, and/or action plan, and Team Care

Arrangement – this supports patient self-management (enablement)

o 50% of patients complete the Patient Enablement and Satisfaction survey (unlikely to

proceed)

o Pre and post comparison in all indicators (assessments, spirometry; GPMP/action

plan/Team Care Arrangement), extracting from PenCAT where possible

http://www.naml.com.au/?page_id=2201


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o Assessment of the number of Do Not Attends (relates to satisfaction with service).

Proceeding with these measures may be difficult as not all practices have client information

systems of high quality, which could render pre-data unreliable – NAML support for clinical

coding and data cleansing did not occur until midway through the project.

Box 5.6 Lung Foundation Australia COPD online training To further add value to the respiratory clinic initiative, an evaluation of the nurses’ participation in the COPD online training was conducted by the Lung Foundation. This online training program aims to increase knowledge, confidence and skills of primary care nurses in identifying and managing patients with COPD, including the development of self-management plans. Data were collected from 11 participants at commencement of training and 10 at completion of the training using a quasi-experimental design. This included pre- (baseline) and post- (immediate follow-up) questionnaires. A report outlining the outcomes of knowledge, confidence and practice, satisfaction and preferences for the nurses who undertook the training indicated that knowledge increased across all eight items measured, with the largest change in knowledge related to recognising that the three main symptoms of COPD were breathlessness, chronic cough and sputum production. Importantly nurses showed an increase in confidence across all 14 items that were measured, with the greatest increases being in relation to: • identifying patients at risk of COPD • developing GPMPs for patients diagnosed with COPD • identifying appropriate medicines for a COPD patient • instructing and supporting patients on inhaler technique • supporting patients to improve patient medicine adherence • developing self-management action plans with COPD patients. Overall, the training was liked by participants and they said that it would help in their clinical practice. Tools and strategies presented were useful, the training was easy to understand, and the flexible learning program met their expectations. It was noted that the training was comprehensive but time-consuming (longer than expected). All five practices now have a respiratory clinic up and running on a weekly basis – this is considered

a good result given NAML’s position was to encourage at least fortnightly clinics. Most of the nurses

can see up to around seven or eight patients per full-day clinic, where spirometry is being performed

and care plans are being created. More patients can be seen when there are a number who have

been recalled for a review as these appointments take around half an hour as opposed to one hour

for a care plan. Most are not currently filling their entire weekly clinic timeslot with solely respiratory

patients and NAML is now looking to provide support and work with these practices to increase the

numbers.

SUMMARY

All pharmacies and general practices in the NAML region were provided with information on the

NRP project, consumer information and support services for asthma, COPD and smoking cessation,

as well as opportunities to undertake relevant training. This occurred through mailouts and the

NAML e-newsletter.

More intensive supports were provided to eight participating pharmacies through the Asthma

Pharmacy Referral Pathway program and the COPD training and support initiative. For general

practices, intensive support was provided to seven practices through the APCC QIP project and to

five (including three of the former) practices to establish general practice respiratory clinics.

For this component of intensive work, participation from priority area organisations was: 7 out of 22 pharmacies (32%) 4 out of 29 general practices (13.8%)


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Positive outcomes have been achieved in each area, particularly from the asthma program with

pharmacies and the APCC QIP project. The respiratory clinics initiative is in its early days – it is too

soon to assess success definitively but it is looking promising. It has been time-intensive, and will

require more investment of time and resourcing yet. There are multiple variables to consider and

risks to manage, however the motivation of the individual practice nurses involved, the suite of

training and resources that has been offered through the NRP, and the interest of the NALHN

dedicated respiratory unit in building a relationship with the practice staff and supporting their

upskilling in best practice respiratory care (see chapter 6) is boding well for the sustainability of the

clinics.

LESSONS LEARNED

The broader GP focus was delayed by the attention being given to the QIP project but, in

retrospect, it would have been optimal for the whole focus on GPs to have started earlier

given their importance in preventing and managing poor respiratory health. However, the

staggered timing of delivering the initiatives did mean that learnings and successes from the

QIP project were used to shape the package of supports offered to all practices in the priority

locations.

This work was much more time-intensive and difficult than expected with each of the four

projects taking up significant amounts of time for the project coordinator and project

partners.

Participation was low and those organisations that were engaged came mainly as a result of

personal telephone calls. Incentives including free training, support with data, resources

such as PiKo-6 starter kits, and CPD credits provided some encouragement. The original

intention of holding an engagement seminar was not progressed and this may have reduced

impact.

Full engagement was also highly variable. For example, one pharmacy provided over 35% of

the referrals to the Asthma Assist infoline whilst two had less than 5% each. NRP partner

and NRP project coordinator feedback suggested that, on reflection, more time could have

been spent talking with pharmacies and practices to make a better judgement about their

level of commitment to each of the individual interventions; this could have resulted in better

uptake and fulfilment of project goals.

Without quality client information systems in general practice and full use of pharmacy

systems, plus a commitment to outcome measurement, it can be difficult to reliably measure

the impact of interventions. Considerable time needs to be spent assisting general practices

to clean and manage their data, however once this expertise and an understanding of the

importance of this is instilled in practice staff, this is an excellent investment in the ability of

practices to monitor and improve their performance on an ongoing basis.

Sending general letters to all pharmacies and all practices was not an effective means of

engagement. At best, it is hoped it raised awareness of the initiative and encouraged some

training registrations.

Engaging other NAML staff worked well, however having a part-time experienced practice

nurse with sole responsibility for visiting practices and upskilling them on best practice tools,

referral pathways, etc. would have been useful.

Evaluation of the Lung Foundation’s COPD Online training resource found it to be effective

in increasing the knowledge and confidence of practice nurses in identifying and managing

patients with COPD.


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It may be useful to present the results of the NRP project to the primary health care community and

seek advice on next steps and engagement into the future. The respiratory clinics initiative looks

promising but still requires considerable input and ongoing support for a period of time to ensure

outcomes can be measured, the model evaluated, and risks managed.

2.3 Identify training needs, options available and promote and support training for primary care practitioners (e.g. GPs, nurses, pharmacists and pharmacy assistants, community workers, etc.) beginning with priority locations and those serving groups at risk.

There were already a number of respiratory-related training opportunities available in the NAML

area, including those provided by partners including Lung Foundation Australia, Quitline and

Asthma SA. The NRP set out to increase the availability of training, encourage and support

participation by services in the priority locations, and integrate training with other initiatives such as

respiratory clinics.

The partners were able to access high quality speakers and encourage attendance at education

sessions. They also provided content for newsletters and mail-outs and were actively involved in

planning and running education events. Overall the feedback for all sessions was positive. Table 5.3

summarises the 13 training strategies supported or organised by the NRP.

Table 5.3 Training undertaken through the NRP

Training need Education response Reach and response

1 Managing asthma in pregnancy

Asthma and Pregnancy seminar in July 2013 by Asthma SA. Held in the NAML area to link with the NRP; general introduction about NRP also provided

21 attended from NAML practices (3 from priority areas); 6 from outside the area. GPs and practice nurses

2 Managing COPD Prof. Peter Frith presented on the revised Australian and New Zealand COPD-X guidelines for the management of COPD – organised by the Lung Foundation Australia. Consultation on the NRP; information on smoking also provided

23 attended from NAML practices (6 from priority areas), 9 from outside the area. GPs and practice nurses

3 Managing COPD including:

Use of the Lung Health Checklist and the PiKo-6

Care planning – what can be done

Mental health and chronic disease

Importance of PR

Integrated care and use of PCEHR

Full-day session for those involved in the QIP project on COPD and interested others. Presenters included: Lung Foundation Australia; local practice nurse; NAML mental health clinical lead; NALHN physiotherapist specialising in PR; NAML staff. Information on funding models (use of GPMPs, etc.) and register systems was included. Pharmacy staff also attended

12 attended from NAML practices (9 from priority areas - 5 GPs and 4 practice nurses); 2 from outside the area; 3 pharmacists

4a Spirometry was not always being used to confirm diagnosis of asthma or COPD

Full-day spirometry training for practice staff, run by National Asthma Council in June 2014

15 from NAML practices (7 from priority areas); 4 from outside the area. GPs and practice nurses. NB: numbers were limited by trainer:participant ratio


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As above – another full day session run in May 2015

4 attended from NAML practices (2 from priority areas); 13 not working in the area. 3 GPs, 4 practice nurses, 10 international medical graduates

4b Asthma SA’s Spirometry Learning Module was offered to ten practice nurses involved in setting up respiratory clinics – this included a web-based component, a four-hour face-to-face practical session (March 2015) and ongoing evaluation of competency with feedback/mentoring to participants over a three-month period.

10 nurses participating from NAML practices, with 9 of these involved in the respiratory clinic initiative (5 from priority areas)

5 Managing asthma in line with the new National Asthma Council Australian Asthma Handbook 2014 Preventing ED attendances through good practice Establishing asthma clinics

Education session held on November 2014, run by Asthma SA and NAML. Modbury Hospital ED acting director, Dr Tim Burrough, and practice nurse/asthma educator presented information

24 from NAML practices (6 from priority areas); 10 from outside the area. GPs and practice nurses

6 Nurses’ confidence and competence in assisting patients with asthma or COPD (and running clinics)

Lung Foundation Australia’s COPD Nurse Training Online was offered in December 2014 to nurses involved in running clinics

10 practice nurses

7a Assisting people to quit smoking and referring appropriately General practice staff

Smoking cessation workshop held April 2015 run by Quitline and NAML with presentations by A/Prof. John Litt, Quitline Team Leader and NRP Project Coordinator Smoking cessation mailout December 2014 (see 1.1)

20 from NAML practices (7 from priority areas); 7 from outside the area

7b Aboriginal Health Workers’ skills in assisting clients to quit smoking

Training of AHWs provided – see 1.1

Seven AHWs attended

7c Assisting people to quit smoking and referring appropriately Pharmacy staff

Smoking cessation workshop held May 2015, run by Quitline and NAML with presentation from A/Prof Litt, Quitline Team Leader and NRP Project Coordinator

26 community pharmacy & hospital staff attended – 24 from NAML (18 from priority areas); 2 from outside the area

8 Lack of knowledge on PR efficacy and service availability

PR incorporated into three above; information included in newsletters

All general practices

9 Referral pathways not clear

A chronic disease referral pathway booklet for general practices, containing dedicated pages with a respiratory-specific

All general practices


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focus was developed by NAML and provided on its website

SUMMARY

Objective 2.1 and 2.2 includes a list of areas prioritised for attention. Table 5.4 outlines the extent to

which these were covered by the NRP project. All received some coverage but there is much more

that can be provided.

Education and training sessions were a popular way to engage health professionals with many

sessions booking out quickly. This was a good way to reach people and the benefit was

considerable with connections made that facilitated subsequent engagement. In particular,

spirometry training is in extremely high demand in the NAML region with all sessions booked out

quickly.

There were 135 attendances at education sessions though some people attended multiple

sessions.

Table 5.4 Coverage of key issues through the NRP

Information, advice and support provided Achieved Comments

Best practice technical guidelines ✓ Via training and key projects

Practice tools information, e.g. register systems, IT

✓ To all involved in key projects

Information on specific service components (e.g. spirometry testing, home oxygen, PR, etc.)

✓ Via newsletters, to clinic staff, via training

Referral pathway guidelines (including proposed specialist multidisciplinary respiratory service, home care supports, etc.)

✓ Partial implementation (not proposed specialist multidisciplinary respiratory service, home care supports)

Funding models ✓ Some information to clinics

Roles and contributions of different players, e.g. GPs, practice nurses, pharmacy, allied health/rehab/physical activity programs, NGO support services, nurse-led clinics

✓ Multiple people involved in training, projects showing different roles, e.g. pharmacists and case-finding

Management of specific conditions, e.g. asthma during pregnancy, managing those with mental illness and respiratory conditions, managing comorbidity

✓ Asthma and pregnancy, asthma and COPD guidelines

Prevention information, including brief interventions

✓ Around smoking in particular, plus case-finding

LESSONS LEARNED

Arranging training was time-intensive for the project coordinator and partners – for example, a

large amount of time was spent encouraging attendance at the smoking cessation workshop for

pharmacists (i.e. individual phone calls and follow-up by email to the priority areas after blanket

promotion across the region) but the feedback was very positive and a high proportion of

attendees were from the priority areas (69%) so the approach did work

The number of ‘Did Not Attends’ at general practice education sessions was sometimes high, up

to 25% (but this is not peculiar to this project alone)

Whilst most training needs were covered, there was no education plan that could have ensured

systematic coverage of issues; this would have been hard given a reliance on partner timetables


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Continue to provide education sessions on key topics integrated with other strategic initiatives.

Pharmacy and general practice reach in the NAML region Pharmacies:

15.7% (13 out of 83) pharmacies participated in one or more NRP activities

36.4% (8 of 22) pharmacies in the priority areas participated in one or more NRP activities (or 23% of 30 pharmacies in or near the priority areas)

46 pharmacists and pharmacy assistants participated in one or more NRP activities General Practices: 45.2% (42 out of 93) general practices participated in one or more NRP activities 34.5% (10 out of 29) general practices in the priority areas participated in one or more NRP activities 102 GPs or practice nurses participated in one or more NRP activities Although not quite at the target of 40% for priority areas the overall reach to both general practices and pharmacies through the NRP project was extensive. 2.4 Contribute advice on gaps in COPD and asthma secondary prevention services/workforce in

the NAML region and options to meet these needs to NALHN and NAML. This might include need for Specialist Respiratory GP, nurse practitioners, etc.

The following gaps were identified during the course of the NRP and addressed in the following

ways:

Lack of integration of primary and acute care – the Hospital Working Group addressed this (see

chapter 6, objective 3.1), and the establishment of general practice respiratory clinics has also

assisted. Further work will occur beyond the NRP

Lack of PR and maintenance programs – see chapter 6, objective 3.2

Lack of respiratory clinics for systematic respiratory care in general practice – see above.

2.5 Contribute consumer views regarding COPD and asthma prevention where possible to

inform good practice care (see chapter 4, objective 1.2) The intention of this sub-objective was to contribute consumers’ views to inform primary health care

practice with disadvantaged communities. Low health literacy levels mean practice needs to be

adapted accordingly. As well as the collection of consumer views outlined under objective 1.2 the

consumer focussed project partners (Asthma SA and Lung Foundation Australia) provided valuable

insight on consumer views throughout the project including through their education sessions and

contact with individual service providers, e.g. pharmacists.

LESSONS LEARNED

It was not as easy to consult with consumers such as those with a mental illness as originally

thought but valuable information can be obtained from every contact with individuals and groups.


Discussion should be held about ongoing practical and systematic ways to incorporate consumer

perspectives into service reforms and education sessions building on the work undertaken to date.


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CHAPTER 6 OBJECTIVE 3 TERTIARY PREVENTION

Objective 3 To rehabilitate as far as possible and to reduce the likelihood of exacerbations or relapses for those with COPD and asthma. Note effective implementation of objective 2 also supports tertiary prevention

The NRP sought to prevent and delay progression of disease to the point where complications are

experienced and admissions to hospital or attendance at emergency departments occurs. Clear

pathways into and out of acute services were identified as a need consistent with the

comprehensive and coordinated approach of the NRP. The NALHN has been a foundation partner

in the project and the overall project goal to reduce respiratory-related admissions and ED

attendances was based on NALHN data.

Tertiary prevention activities identified in the NRP project plan were: 3.1 Ensure hospital (inpatients and ED) responses support good management (information,

referrals, coordinated care, etc. – clinical care not in scope) of patients using the service and build effective primary care / acute care collaboration

3.2 Maximise use of hospital avoidance services, especially pulmonary rehabilitation for those with complex needs

Implementation of key activities

In practice the activities undertaken under 3.1 and 3.2 were intertwined and are reported together.

In early 2014 a working group was established to identify in-hospital responses to preventing and

better managing COPD and asthma ED attendances and a plan prepared (see Appendix 5).

The group held five meetings over a period of seven months plus a follow-up review meeting to

contribute to the evaluation and identify areas for further action. Discussions with medical and

nursing leadership informed the need to set-up the group. Two sub-groups were also established:

one to review asthma inpatient management and discharge protocols and a second to identify ways

to address the need for PR programs in the region.

Whilst initially the focus of the working group was the Lyell McEwin Hospital this was changed to

cover both major NALHN hospitals – the Lyell McEwin and Modbury Hospital – as well as the

interface with the primary health care sector.

Appendix 6 provides a detailed summary of the issues progressed through the working group.

Smoking and health literacy issues have been covered earlier in this chapter. In summary, the

following were achieved:

Support for primary health care

Linkages between the five new General Practice Respiratory Clinics (GPRCs; see chapter 5) and

NALHN. This includes:

GPRCs agreeing to take on hospital respiratory patients who do not have a GP

Hospital staff informing GPRCs about the Medical Quick Access Clinics (QACs) and relevant

criteria, identifying practice information and education needs and building relationships. QACs

have been introduced to provide an alternative for patients who do not need to be seen at an ED

but cannot safely wait for an outpatient appointment, ensuring a timely response to the medical

problem in collaboration with primary care services. This also addresses outpatient waiting lists.

Testing the 24/7 access to the on-call respiratory consultant with the GPRCs prior to promoting

more broadly to all practices

Priority referrals of GPRC patients to the QACs established by NALHN.


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In addition, work underway at the time of writing includes:

Developing a desktop-based checklist to support appropriate GP referrals to respiratory

specialists

Mental health

The no-cost NAML Living Well with Serious Illness program for people living with progressive

life-limiting illness (including COPD) and experiencing anxiety or depression has been promoted

within NALHN and to GPs. Referral requirements have also been clarified.

Guidelines

In September 2014 NALHN adopted the state-wide Paediatric Asthma guidelines for use across

the service with work underway to ensure uniform implementation of the guidelines across the

health service. A state-wide group is reviewing consistency with the National Asthma

Guidelines.

The COPD discharge resource has been updated including a guidelines compliance review

On advice from NALHN Pharmacy the antibiotic to be included in the COPD emergency pack

has been standardised.

Quit smoking

Working with the Quitline on NALHN strategies to support patients and staff to quit smoking (see

chapter 4)

Box 6.1 Hospital Working Group reflections on the NRP

At their final meeting members of the Hospital Working Group were invited to provide an overall assessment of the project including what had worked well and what could be done differently next time. Feedback was provided at the meeting but participants were also invited to send private comments (none received). Comments included: Respiratory health need

The project has raised awareness about COPD, asthma and smoking cessation support and highlighted service needs and gaps

PHC – acute interface

The five general practices implementing new respiratory clinics is a good way to pilot new initiatives such as the QACs. Linking with primary care services is really important

There are some good opportunities to bring GPs and specialists together on some specific topics and practical ideas – it would be good to progress this

It is clear that there is a need to share information about what services are now provided in the hospital

Role of the NRP

The NRP project has enabled coordination and facilitation around a variety of respiratory issues and with many different groups. The various hospital working groups assisted internal communication between staff/units at the NALHN around work happening in the COPD/asthma space, providing a forum for staff to raise issues encountered in their work areas and discuss ways to address these – in some cases quick solutions were identified; in others longer-term efforts were kick-started. The ‘legs and arms’ of the project built trust and connections and were vital to achieving outcomes, and bringing people together around the table meant that actions/decisions could be formulated and agreed upon quickly.

The working group (and sub-groups and actions arising) has helped to build connections and trust between organisations which helps with sustainability. For example, discussions are underway between the hospital and Asthma SA about better meeting the needs of children and young people in the region.


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Membership

The perspective of the participating GP is invaluable providing a useful reality check on the feasibility of adoption of things like guidelines in primary health care. Very valuable input.

A lot of children attend hospital with asthma and possibly a stronger paediatric perspective might have been useful.

Context

The timing was difficult as NALHN did not have a dedicated respiratory unit until recently. Now with positions filled and respiratory physicians in place a lot more can be done, in particular the acute/primary care interface

“The NRP project has enabled fantastic coordination and facilitation around a variety of respiratory issues and with many different groups.”

-- NRP Hospital Working Group Participant

SUMMARY

There have been some very positive outcomes from the work with NALHN through the NRP. A

wide-ranging work agenda was progressed (as described above) through the working group and

most members remained engaged throughout the project. Two working groups were supported.

Links between the NGOs (Asthma SA, Lung Foundation Australia and Quitline) were strengthened

through joint training, resource sharing and the provision of specialist input. A collaboration was built

that had not existed previously and the connections facilitated other work, e.g. a pharmacist who

participated in the NRP initiative will present to the Breathless in the North group facilitated by a

hospital respiratory nurse.

As the dedicated respiratory unit at the hospital was not fully established until later in 2014 some

initiatives were put on hold pending this development, e.g. guideline reviews and visits to practices.

LESSONS LEARNED

It is useful to have a working group involving the acute and primary care sectors with sub-groups to

act on particular strategies.


The Hospital Working Group has agreed to continue to meet quarterly into the future. An important

focus will be building bridges with primary care, including raising awareness of the new NALHN

dedicated respiratory unit with GPs in particular. This is likely to involve education for doctors

around medicines and devices. Links with general practice clinics will also be supported to build

good relationships and referrals. A focus on children and asthma will occur, in line with the LHN

focus on how to better manage asthma in ED; NRP partners are likely to be involved.

Pulmonary rehabilitation

Pulmonary rehabilitation (PR) is one of the most effective interventions in COPD63,64 and has been

shown to reduce symptoms, disability and handicap, reduce hospitalisation65,66 and to improve

function. PR should be offered to all patients with chronic respiratory diseases (particularly COPD,

bronchiectasis, interstitial lung disease and pulmonary fibrosis), irrespective of the severity of their

disease.


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The COPD-X Guidelines state:

PR reduces dyspnoea, fatigue, anxiety and depression, improves exercise capacity, emotional

function and health-related quality of life and enhances patients’ sense of control over their

condition (level I evidence)

PR reduces hospitalisation and has been shown to be cost-effective (level II evidence).

Further compelling evidence comes from a Cochrane review by Puhan et al. 67 which found that for

those who had PR within 28 days after an exacerbation, only 13% were readmitted to hospital

compared to 40% readmission for those who did not have PR. This resulted in numbers needed to

treat (NNT) being only four patients to avoid one hospital admission.

All people with COPD should be offered timely access to PR, that being a combination of exercise,

education and psychosocial support. Ongoing support programs and maintenance exercise

programs such as Lungs in Action post-PR are important services to establish and will assist in

maintaining gains for those with impaired respiratory function.

A gap analysis conducted as part of the NRP project identified the need for additional PR and

maintenance exercise programs in the NAML region, with limited availability of programs and,

consequently, long waiting lists. Priority is given to those with more severe COPD, while those with

moderate COPD are wait-listed. Long waiting lists appear to be discouraging referrals, making it

difficult to increase patient access by simply raising awareness about the benefits of PR.

A Pulmonary Rehabilitation Working Group comprising NALHN, NAML and Lung Foundation

Australia staff was set up with the goals of increasing awareness amongst primary care providers of

the benefits of PR and maintenance exercise programs for patients with COPD, increasing the

number of PR and maintenance exercise programs available and increasing patient participation.

Key issues identified

There is limited access to PR in the NAML region due to there being only two public services

running a PR program (i.e. Lyell McEwin Hospital and Gawler Health Service), with both of

these having waiting lists of some weeks/months

Referrals to PR services from general practice are low but given the limited placements

available it is problematic to promote further

There are also maintenance exercise programs which are under-utilised

There are private physiotherapy services and one private PR provider but cost would be a

barrier to many in the NAML region

Knowledge of the benefits and availability of PR may be limited in general practice and with

consumers; PR is not an automatic component of GPMPs for COPD

There are currently no clear referral risk stratification guidelines available in relation to local

hospital PR, community PR and community-based exercise programs, e.g. the latter may be

suitable for people with COPD of lower severity

Not all services are connected to the Lung Foundation Australia for support, updates, training

options, etc.

There were nearly 1300 admissions to hospital for COPD in 2012 for people living in the NAML

region; this may include multiple admissions (see chapter 3 for more information) but we

estimate around 1000 people could benefit from PR in one year. There are not sufficient

services for this number of people.

Consumer barriers

As part of planning ways to improve the numbers attending PR, phone interviews were conducted

(using a standard set of questions) with five northern Adelaide service providers currently running

http://copdx.org.au/


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community PR and maintenance programs. They identified that consumers face a number of

barriers to attending and completing PR. This includes:

Never exercised before and feel it is too late to start

They may be too unwell, too short of breath

They may believe they do not need PR and be sceptical about it working in eight weeks

They have neither been informed about the benefits of PR nor been encouraged to attend

Lack of transport and services may be some distance from home.

Consumer enablers

The same providers also identified the following supports for attendance at, and completion of, PR:

Free health assessments

Good rapport between the health professional and consumer

People want to and do feel better and have more energy – once experienced, this encourages

further participation. Results can be measured through improvements in the six-minute walk

test

The social connections - people are very supportive of each other and share problems, e.g.

dealing with anxiety and depression, often share meals and information. They see others have

similar problems (this can also be a barrier if COPD is only mild/moderate)

The programs are fun and non-threatening.

Kylie Johnston’s research with 12 Adelaide GPs showed four major categories of barriers to referral

to PR: low knowledge of PR for COPD; low knowledge of how to refer; actual or anticipated access

difficulties for patients; and questioning the need to do more to promote exercise behaviour change.

Awareness of benefit was the only current facilitator.68

Other research with 88 patients admitted to a major Adelaide hospital found that while 57% had

been referred to rehabilitation during their disease course, only 18% had attended and completed at

least half the programme.69

What has been done so far?

A PR Working Group was set up at the Lyell McEwin Hospital to brainstorm ideas to tackle the

supply/demand problem and feasible solutions, formally meeting twice and communicating

progress against actions by emails in the form of an updated action plan

An audit of all PR services in the NAML region was undertaken

A chronic disease referral pathways booklet for general practice was developed by NAML and

launched in 2014. The Respiratory section includes a spreadsheet on PR programs,

maintenance exercise programs and community-based physical activity options in the region.

This is available at: www.naml.com.au/?page_id=2201. Maps also show locations of these

services – see Appendix 7. GP practice visits in the future will promote this information and the

importance of referrals.

NAML met with the two other SA metropolitan Medicare Locals in August 2014 to discuss

possible collaborative work with respect to existing service gaps for COPD patients, with a focus

on PR

Information was provided to GPs and practice nurses on the efficacy and benefits of PR through

the COPD Management workshop in June 2014, and via newsletters, mailouts, etc. Advice on

service availability and referral mechanisms was also included. The Lung Foundation Australia

provided an update to Lyell McEwin Hospital staff on COPD, PR and lung health in mid-2014.

SA Health have approved hospital physiotherapists mentoring community PR providers.

“These maps are really great! They show at a glance where the service gaps are” -- NRP Hospital Working Group Participant

http://www.naml.com.au/?page_id=2201


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SUMMARY

A solid foundation has been laid to progress development of additional services for people in need

of PR in the NAML region. The partnerships are in place with the right people involved, strategies

have been identified (see ‘Proposed Way Forward’ below), an audit conducted and shared, and

partners have essential experience and advice to help this progress.

LESSONS LEARNED

This was a project that would have benefitted by more time than was allocated to it, e.g. a three-

month intensive focus, and perhaps some seed funding for private providers to set up a program.

The ‘urgent’ tended to crowd out the more long-term work. If setting up a focus area, ensure there is

sufficient commitment of time to action the work agenda.


Ensure sufficient access to PR and related programs through a whole-of-Adelaide metropolitan

region collaborative planning and implementation process

Explore potential for new services including Lungs in Action and PR programs in the community.

Look at use of private and community facilities, different models and providers, links with other

programs, e.g. chronic heart failure and, if feasible, support establishment of new services

including upskilling exercise programs to maintenance programs

Determine and promulgate care pathways and guidelines, e.g. use of risk stratification tools.

Categorise different programs e.g. PR, maintenance programs and community exercise

programs.

Continue to encourage referrals to PR and related programs upon diagnosis. Ensure health

practitioners understand the evidence on the efficacy of PR, feel confident encouraging patients

and can readily refer to PR programs

Upskill and mentor PR and related providers and link together for cross-referral and problem-

solving. Link all PR providers with Lung Foundation Australia

Publicise stories of consumers who have benefited from attending PR. Work to overcome

patient barriers such as lack of knowledge of services.


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CHAPTER 7 OBJECTIVE 4 A COORDINATED COLLABORATIVE APPROACH

Objective 4 To establish a comprehensive coordinated whole-of-community approach to the prevention of COPD and asthma

Obj 4.1 Appoint a project coordinator

Obj 4.2 Undertake a stocktake of current COPD and asthma-related services, guidelines, programs, tools, workforce and practices in the NAML region to inform gaps, overlaps and opportunities

Obj 4.3 Prepare comprehensive data report; use the data to inform program and service priorities particularly where to reach the vulnerable groups

Obj 4.4 Develop partnerships for solution-focussed results

Objective 4 reflected the broad approach of the NRP. The project was based on establishing a

partnership to work on an integrated and coordinated approach to respiratory health in the NAML

region. The plan developed was bound by the budget allocated for the project. Four sub-objectives,

each with related activities, were developed to achieve project outcomes.

Objective 4.1 Appoint a project coordinator

A project coordinator was required to manage the implementation of the NRP project.

Project coordination activities identified in the NRP project plan were:

4.1.1 Provide high level project leadership throughout the two years

4.1.2 Plan the initiative and lead the implementation and document the model

4.1.3 Develop and maintain effective partnerships and commitment with all key players including consumers (taken here as the formal NRP partners)

4.1.4 Identify health economics expertise

4.1.5 Liaise with ANPHA regarding evaluation


Plan and lead the initiative over two years

Commencement of the project was somewhat delayed while the auspicing agency, NAML,

transitioned to a new governance structure. A (part-time) project coordinator was appointed in May

2013 but moved to a job in another organisation after three months. There was a period of time where

the project advisor acted in the position before a second project coordinator commenced. The second

coordinator was in the position for seven months. In May 2014 the third project coordinator began and

remained for the project duration working full-time. The reasons for the turnover were largely personal

but partly the size and scope of the project. Overall, the turnover of staff in this position has had a

significant impact on implementation, causing delays, loss of continuity and additional expense. In

reality there has been around 21 months of implementation rather than the planned 24 months.

The evaluation has been conducted by Michele Herriot (Health Promotion Consultant). She has been

involved in the NRP project throughout as a project advisor. This has assisted with continuity given the

staff turnover. Periodically throughout the project the PMC tracked progress against key indicators

using a traffic light system and identified areas of concern and possible solutions.

Achieving comprehensive change across the continuum of care is challenging and the project

coordinator was required to work on multiple sub-projects simultaneously. The NRP project plan had

broad strategies and indicators along with timelines and detailed plans were developed for several

interventions.


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NRP progress reports to funders commented repeatedly on the project challenges as shown by this

example:

The key challenge is progressing the multiple strands of the project concurrently. Our approach is underpinned by the evidence that to make a difference we need sufficient ‘dose’ of effort and that this can best occur by having a concerted, coordinated focus on the issue – i.e. respiratory health of people living in the NAML region. We are working across the continuum of care to have ‘joined-up’ and complementary solutions, with multiple stakeholders, professional groups and organisations engaged in initiatives that are targeted more intensively to areas of highest need as determined by data and insights provided by project partners. We are confident this is the best approach, however each of the 14 objectives (activities) is almost a project alone and some have proved harder than others.

-- September 2014 report to Australian Government Department of Health

The NAML Health Integration Manager was responsible for providing overall leadership and direction

throughout the NRP project, whilst the project coordinator operationalised the project plan and

managed the partners and service provider relations, including in pharmacies, general practices,

community organisations, Aboriginal services, the acute care sector and private providers. One

coordinator commented that a significant part of the role was facilitating connections between people,

projects and organisations and identifying opportunities for expansion of existing, and creation of new,

projects and activities with partners and across the region. All three project coordinators received

positive feedback and were considered effective in achieving the role.

As the project progressed implementation was adjusted to suit the environmental circumstances and

take advantage of opportunities. Many of the changes have been documented elsewhere in this

report. Practical support from other NAML staff was provided through the communications team,

administration, Aboriginal and mental health teams. The part-time nurse position originally in the plan

was not appointed due to difficulties attracting a suitable applicant. Instead NAML staff filled this role.

Significant implementation did occur yet the breadth of the project worked against achievement of

some key deliverables. There were 15 objectives and multiple sub-objectives and activities. Elsewhere

this report documents areas that have progressed and others where more limited progress was made.

Lack of progress on some activities was more due to overly ambitious planning than poor

implementation. It was not possible to progress all activities set out in the plan given the resources

available, which included having a full-time rather than the proposed part-time project coordinator in

the role for the latter half of the project. Some activities, including community and clinician

consultations, were not progressed until later in the project lessening their impact on the project

implementation. Earlier seminars could potentially have increased awareness of the NRP and

increased engagement by clinicians.

NAML and the PMC monitored progress regularly and there were specific deliverables for activities.

In terms of documentation of the model, this report serves to achieve this intention.

SUMMARY

The NRP had skilled and experienced project coordinators with a track record of working

collaboratively with others and good project management skills. This was a significant contributor to

achieving the project outcomes.


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LESSONS LEARNED

Although a comprehensive approach across the continuum of care is required to make a difference

to chronic disease it could be better to focus in on a more limited number of objectives to facilitate

outcomes.


Any expansion of the NRP should continue to have a skilled project coordinator and include a

project plan with specific initiatives. Consider progressing fewer areas more intensively but within

the context of a broad approach.

The NRP Partners

Note: this section reports on relationships with formal NRP project partners, with activity 4.4 referring

to other partnerships with key stakeholders and consumers.

All of the NRP partners have been highly committed to the project and the partnership. With few

exceptions, all partners attended PMC monthly meetings showing an exceptional level of sustained

commitment over a period of two years. This reflects positively on both their investment in the project

and the perceived value of the work to their organisation. Representatives regularly challenged the

approach being taken, in a productive way. Examples included evaluation discussion, progress

against deliverables, priorities for action and best strategies.

The VicHealth Partnerships Analysis Tool was administered to PMC members at baseline, midway

through the project and in the final month. Results each time confirmed that “a genuine collaboration

has been established” with the average overall score increasing (in a positive direction) over the two

years as shown in Table 7.1.

Table 7.1 VicHealth Partnerships Analysis Tool results

Baseline May 2013

Mid-project June 2014

Project conclusion May 2015

Score 136/175 144/175 155/175

Checklist score A genuine partnership has been established

A genuine partnership has been established

A genuine partnership has been established

All partners responded to a series of questions about their involvement in the project (Appendix 8).

Table 7.2 provides a summary of the main areas of involvement of the partners and this is followed by

a summary of partners’ reflections on the NRP project and their participation (Table 7.3).

Table 7.2 Areas of involvement of major NRP partners (in addition to PMC participation)

Organisation Involvement

Northern Adelaide Local Health Network

Chaired all Hospital Working Group meetings, engaged key acute care staff, followed up multiple issues

Facilitated the PR Working Group activities

Facilitated ad hoc meetings with senior staff

Contributed advice on data and literature reviews

The Partnerships Analysis Tool results confirmed that “a genuine collaboration has

been established”.


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Participated in project coordinator recruitment

Facilitated NALHN / NAML attendance at the Health Roundtable on COPD

Drug and Alcohol Services SA

Prepared the smoking cessation support package for GPs, including the Give up smokes for good campaign materials targeted to Aboriginal patients and other more generalised smoking cessation information such as evidence of Quitline effectiveness, etc.

Determined which general practices to offer more intensive supports (see objective 1)

Co-led the Aboriginal Tobacco Round Table, presented information and worked with key partners

Worked with NAML and SAHMRI to progress the methodology for the (delayed) Supporting smoke-free pregnancies among Aboriginal women and their families project once the opportunity arose for this to again be pursued

Arranged smoking-related data and briefings

Linked Quitline into the project which proved to be very valuable given their work with practitioners and consumers

Pharmaceutical Society Australia (SA/NT Branch)

Co-led the pharmacy intervention (with Asthma SA), had regular liaison with pharmacies and assigned CPD credits to individual pharmacists

Co-organised the Smoking Cessation Workshop for pharmacists with Quitline and NAML, including active promotion to pharmacies in the NRP priority locations

Provided ongoing advice regarding the pharmacy sector

Promoted the NRP and its pharmacy-related initiatives in its newsletters

Conducted interviews with pharmacists involved in NRP initiatives as part of the overall project evaluation effort

Asthma SA Co-led the pharmacy intervention (with PSA), provided training to pharmacies

Provided phone advice to 113 people through the pharmacy initiative (funding provided). Undertook 1-month and 12-month follow up and presented on this work at the Asthma Australia Australasian conference in May 2015

Provided asthma/COPD update training to RACFs and education settings (funding provided)

Provided ongoing advice regarding asthma and prioritised the northern area for asthma-related seminars e.g. Ask the Experts, Asthma Management Handbook 2014

Were key in the planning and development of the GPRC initiative, including provision of asthma resource kits and by facilitating intensive spirometry training

Contributed expertise to an asthma guidelines working group at NALHN


Reviewed documents, plans and contributed to discussions

Worked with local groups to engage them in World COPD Day activities

Reviewed APCC COPD project implementation plan for NAML and assisted in development and delivery of training workshop, including presentation on case finding for COPD

Evidence on PR and support for local service providers on available funding models and delivery including maintenance exercise programs, i.e. Lungs in Action

Sourced community providers for potential Lungs in Action and PR programs

Sourced speakers for workshops

Provided linkages to national and international evidence and best practice


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Ongoing advice to project coordinators

Major contribution to COPD component of pharmacy intervention; provided training to pharmacies; provided resources and evaluation advice

Were critical in the planning and development of the GPRC initiative, including provision of COPD resource kits and by facilitating COPD nurse online training

Northern Region GP Council

Provided regular advice on medical and general practice issues to ensure that initiatives targeted to general practice would be useful, effective and appropriate (in some cases liaising with the NRGPC on these issues)

Provided updates to NRGPC on NRP initiatives

Participated in the Hospital Working Group and other ad hoc meetings

Reviewed documents and contributed to discussions

Quitline Provided information on the Quitline at multiple events

Co-organised the Smoking Cessation Workshop for pharmacists (with PSA and NAML)

Have commenced undertaking in-practice training and pharmacy visits

Provided resources for mailouts and events

Provided Quitline calls data and Quitline referral data from the NAML region

Working with NALHN to enhance smoking cessation supports for patients and staff at the two local hospitals

Box 7.1 Summary of the NRP partners’ reflections on the project

A summary of partners’ reflections on the NRP included:

What impact did your organisation’s involvement have on the outcome of the project?

By providing necessary skills, expertise and knowledge on best practice, the seriousness of the

respiratory issue and the need for action this ensured a quality approach in the NRP. All partners

had a strong commitment to making the NRP work well

Providing advice on what others are doing in the respiratory field helped inform directions

Positive impact on the overall outcomes of the NRP through conduct of particular initiatives

Brought credibility and some prestige to the NRP

Positive influence on decision-making processes through accountability and responsiveness

Value adding through the in-kind contributions

Influenced respiratory management practices through dissemination of information, training,

education, resources and advocacy

Helped reach and understand the needs of pharmacies/pharmacists/general practice to a greater

degree; this was reflected in the positive outcomes in, for example, the pharmacy evaluations.

Have there been changes in practice or service provision in the NAML region as a result of the

partnership?

The APCC had good results. There has been some progress with pharmacies but would have

been good to have progressed PR

Involving Quit on the PMC led to a real impact on the ground

Enhanced awareness of respiratory health resulting in a higher profile of the conditions

Pharmacies more aware of NGO services and programs and established a referral pathway


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The consciousness of general practice about respiratory disease has been raised. People think

more about COPD and asthma as a result of the education activities

Service providers have increase confidence in management of respiratory health

Self-reported behaviour changes towards asthma by those living with the condition as well as

increased ownership of Asthma Action Plans and increased use of spacers by people living in the

region who were reached through the Asthma SA initiatives

More of a collaborative relationship between NRP partners and other service providers in the

region due to exposure through NRP.

What if any were the benefits for your agency? Was this shared with others in the agency?

Good to work with other members of the NRP who have been willing to share their ideas,

resources, and expertise; sharing and being able to promote things via the PMC has been very

useful

Participation enhanced the skill set of our staff through exposure to other agencies and their

projects

Gained valuable experience working in the northern region of Adelaide and established ongoing

links/relationships with other service providers in the region. Organisational profile enhanced

through participation

Connecting locally with services and building a service profile, e.g. with GPs for LFA, with CTG

team for DASSA

NAML backing in relation to the Smoking and Pregnancy project was very important

Help with contacting GPs around smoking and the Give up smokes for good campaign

Information to general practice on respiratory health, e.g. benefits of PR; opportunities for

education

Benefits of the partnership outweighed any perceived costs.

What were the negatives if any of being involved in the NRP?

There are always competing demands on time and a feeling of ‘could have done more’. The PMC met

monthly. This imposed a considerable demand on partners and did not allow enough time to progress

actions between meetings. Participating by teleconference was very difficult.

Were there any unintended effects of the partnership – positive or negative?

The PMC functioned really well.

With the benefit of hindsight what should the NRP have done differently in relation to: the

project as a whole or your involvement as a partner?

Possibly thinking about other options to progress work with mental health and local government on

smoking given the cuts to tobacco-related services

Taken a more careful approach to working with pharmacies – the focus was on getting the

numbers for the project but should have screened them more carefully, otherwise time is spent

investing in services that cannot come up to speed

Progressed the PR work

Community consultation was done at the wrong end of the project; it would have been good to

have more consultation – people like to be asked for input


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Often we don’t acknowledge little steps – even if you get some change in some people it is worthwhile” -- NRP project partner

“Good things happen because relationships work well” – NRP project partner

Included a budget for face-to-face visits for interstate partners Northern Respiratory Partnership

Final Project Report – May 2013 to May 2015

Ensure that roles and responsibilities of the various partners, project advisor and project

coordinator are delineated as far as possible in relation to each initiative.

What would you do differently if you were approached to be involved in a similar project in the

future?

Possibly consult more on the scope of the project

Take into consideration the lessons learned through the NRP and project outcomes and be more

realistic about setting aims and anticipated outcomes

We would be interested in investigating ways in which to involve more/all partners into each

initiative, not just the initiatives related to the field in which each partner works.

Probably couldn’t again commit the level of resources that have gone into the NRP – provide more

of a consulting role, less meetings.

The application indicated you would make an in-kind contribution. Is this close to what

occurred?

All commented that taking into account their time their contribution was significantly higher than the

amount indicated in the application.

NAML was required to have in place the requirements to ensure this initiative is well managed,

accountable to the funder, the partners and the community for processes and outcomes and

works hard to achieve the best results in the limited time available. Did this occur?

There was positive feedback on the management and oversight of the project, chairing of the

PMC, the work of the project coordinator and having continuity through the project advisor.

Partners were chosen strategically and there were appropriate governance arrangements were in

place to ensure the project remained on track and as per the contractual agreements

Reports to funders could have been distributed earlier

A lot of time and continuity was lost with staff changes – meant more work for partners having

repeated conversations

Clear communication channels were established and maintained.

Is the partnership likely to continue in some form?

The concept of the partnership is good. It would be very good to keep the partnership going even

meeting less frequently

Links established with the Lyell McEwen Hospital have resulted in ongoing work and contribution

to a working party looking at smoking cessation as well a working group aimed at improving

paediatric discharge planning

Asthma SA will continue to work with pharmacies in the region to ensure continuance of the

pharmacy referral pathway.


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LESSONS LEARNED

The partnership model worked well and helped achieve good outcomes. If the project expands or

continues the PMC is valuable but should only meet monthly in the set-up phase and then move to

two-three monthly.


The NRP partners are keen to work with the new Adelaide Primary Health Network, the Northern

Health Network and with each other, continuing to build on the work commenced.

Health Economics Advice

It was the intention to obtain health economics advice for the NRP project. A meeting was held with

the University of Adelaide and there were possible directions identified including a focus on specific

projects such as the asthma and pharmacy project or doing a more sophisticated costing of the project

components. The latter would have helped apply existing costing methods to our complex community

based intervention and been a step towards doing better cost benefit studies for this kind of

intervention, however, the demands of the project meant this was not pursued. This would be useful to

do in the future but requires considerable work to scope and conduct the evaluation. A budget was

allocated but was not sufficient to buy extensive input. This was reallocated within the project.

LESSONS LEARNED

Identify a tertiary sector partnership for health economics advice early on in the project


Any health economics work requires specific funding and a relationship with the tertiary sector.

Possible work includes an economic evaluation of the asthma and pharmacy project as well as

how much money is saved by a reduction in smoking rates and/or reduction in hospital admissions

and ED presentations. Neither of these would be easy.

Work with the funders regarding the evaluation

ANPHA provided advice on the project planning and identification of all objectives, indicators and

evaluation tools. This ceased with the closure of ANPHA in mid-2014.

Objective 4.2 Undertake a stocktake of current COPD and asthma related services, guidelines, programs, tools, workforce and practices

A stocktake was undertaken at baseline however this was not formally maintained throughout the

project. In some areas, such as pulmonary rehabilitation (see chapter 6) a complete list was obtained

and made available via the NAML website. A list of all education organisations, RACFs, general

practices and pharmacies provided the baseline for interventions.

Objective 4.3 Prepare a comprehensive data report

Collect and use data to inform the NRP

A comprehensive data report was prepared to inform the project directions, priority areas, baseline

and needs. Information on the data and its use is presented in chapter 3.


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Objective 4.4 Develop partnerships for solution focused results

Aside from the formal NRP partners (discussed above under The NRP Partners) there were

relationships developed and existing partnerships strengthened with various stakeholders, including

with service providers and different organisations.

Engage with key stakeholders

Examples of partnerships developed throughout the project are:

Closer collaboration between the Living Well with Serious Illness program team at NAML and the

hospital staff which is important given the impact of poor mental health on chronic disease self-

management

High level engagement with the eight pharmacies, the seven practices involved in the APCC

Quality Improvement Partnership project on COPD and the five practices establishing the GPRCs

as outlined in chapter 5

GPs and practice nurses engaged with NAML, the NRP and its partners through training and

specific projects

A local practice nurse conducted a care planning session as part of the APCC full-day workshop

and has gone on to set up a practice nurse network for those working in the NAML region (this is a

forum through which respiratory health can be kept high on the agenda)

Much stronger relationship with various sections of NALHN (see chapter 6) e.g. respiratory nurses,

paediatrics, pharmacy etc. Collectively, these staff made a significant contribution to the project

through the hospital working groups.

The Northern Region GP Council provided advice on a number of occasions, including advice on

discharge planning and communications to GPs as well as being a formal partner

Connection with a number of Aboriginal organisations through the Tobacco Round Table (see

chapter 4). This includes Nunkuwarrin Yunti and AHCSA

Researchers at the SAHMRI are working in collaboration with DASSA and NAML to progress a

project aimed at supporting smoke-free pregnancies among Aboriginal women and their families.

SAHMRI is seeking to engage other partners and an application has just been submitted for

funding.

Under the ANPHA agreement host Medicare Locals were required to participate in the ANPHA

Project Managers Teleconference and contribute to the Preventive Health Matters webtool. This

occurred and the NRP was one of the early projects presented on the webinar.

NAML decided against holding a planning forum early in the project as it was felt it was better to go to

a forum or series of forums with a specific proposal drawn from consultations. In the end this didn’t

occur as progressing individual projects overtook the bigger picture and organisational changes meant

some loss of continuity. This had the effect of limiting the potential engagement of the primary care

sector. Forums were held by Greater Metro South Brisbane Medicare Local and there was a high level

of engagement so they could have been successful in northern.

As identified in chapter 4 there have been gaps in engagement with consumers.

SUMMARY

The NRP evaluation shows that stakeholders are interested in working together to collaborate on

initiatives. Many contacts were made and partnerships formed – these relationships will assist future

progress in improving respiratory health across the northern Adelaide region.


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LESSONS LEARNED

Engagement takes time and needs to happen early as well as throughout the project.


Future work in respiratory health should continue to build relationships with key stakeholders and

organisations that can work together to bring about change.


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CHAPTER 8 DISCUSSION AND CONCLUSIONS

This final chapter sets out the broader lessons from the evaluation and provides advice for future

work on improving respiratory health in the northern region and potentially more broadly across

Adelaide.

PROJECT OUTCOMES

The Northern Respiratory Partnership project had an overall goal of reducing avoidable hospital

admissions or ED attendances by 10% for COPD and asthma in the Northern Adelaide Medicare

Local region by 31 March 2015. This was not achieved, however, a ten percent reduction was

always an aspirational target. The data shows no significant changes in any of the key areas

(asthma, COPD, ED, admissions) as outlined in chapter 3. Potential reasons include:

Lack of sufficient reach to, and intensity of effort with, general practices in the areas where there

were high admission and ED attendances

A focus on highly disadvantaged locations where change may be more difficult to achieve and

take a longer period of sustained effort

A stronger focus on adults than children though children make up 20 percent of admissions and

33 percent of ED attendances

A ramping up of the dedicated respiratory unit at the NALHN hospitals occurred late in the

project. Now that this is in place hospital respiratory medical staff will be able to liaise with

general practice and provide support for primary care respiratory management

There was a bad influenza season in 2014 and bushfires with higher ED attendances in early

2015

Consistent with the project plan the NRP had a concerted focus on primary and secondary

prevention including smoking cessation activity where the gains will be long- rather than short-

term

Two years is not enough time to make an impact.

Advice from the Health Roundtable suggested hospitals pay attention to ensuring hospital

admissions are accurately and consistently coded in line with guidelines. This has not impacted on

the data used for the NRP goal but future action could consider this issue.

Appendix 9 provides a full summary of the achievements against all of the process and outcome

indicators in the NRP project plan. These have been reported on in earlier chapters. Overall there

has been good progress. Successes include:

A reduction in smoking prevalence in the NAML region – the NRP project is not entirely

responsible for this positive result but made a contribution to its achievement

Provision of various ‘enablers’ for quit smoking support including training, electronic referral

systems, multiple partnerships and plans including with the LHN and distribution of resources.

This has provided a good base for further action

Increased capacity of schools to respond to children with asthma through asthma first aid

training for school staff. Training was provided to 74% of schools in priority areas and there was

more than a 20% increase in the number of schools trained in non-priority areas.

Regular respiratory health and smoking awareness-raising activities targeted to the community

and primary health care providers

Practice improvements for the eight pharmacies and nine general practices (most of which were

in the priority locations) receiving intensive support. This includes referrals to consumer support


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services, improvements to clinical information systems, regular recalls of people at risk and staff

skills. Although not quite at the target of 40% for priority areas the overall reach to both general

practices and pharmacies through the NRP project was extensive. There is some evidence of

increased early identification and effective management of asthma and COPD for participating

organisations

CPD credits were provided to 11 pharmacists with more to come

Seven practices participating in the QIP project conducted 429 COPD screenings

There were 165 people referred from eight pharmacies to the Asthma Assist infoline. Follow up

of 34% of people showed:

o asthma management scores increased from 15.47 at baseline to 21.24 after 12 months

o 69% had an Asthma Action Plan (22% at baseline)

o 79% were using a spacer (35% at baseline)

o 85% had a GP review (54% at baseline)

o there were fewer hospital admissions.

There were around 170 training sessions received by service providers with 13 formal sessions

held over the two years as well as a number of practice visits (some attended more than one

session so this does not represent 170 individuals). This ‘blitz’ has both increased knowledge

and skills and enhanced interest in and commitment to respiratory health

Overall around 15.7% of pharmacies and 45.2% of general practices engaged in one or more

NRP activities. This figure was 36.3% and 34.5% respectively of those in priority areas,

approaching the 40% target

Improvements in hospital systems, e.g. paediatric asthma management protocol and review and

update of COPD emergency pack for patients discharged from ED and the COPD discharge

action plan for those discharged from Inpatients

Implementing a comprehensive, coordinated whole-of-community approach to the prevention of

asthma and COPD with tangible examples of this approach

Effective use of the data to identify priority locations and to track progress

Building a strong foundation for work between the acute and primary care sector – this should

not be underestimated and stands in good stead for future activity

The relationship between all the project partners providing a base for sustainable approaches.

Areas where limited progress was made include:

Consumer engagement and understanding of the barriers that consumers face in accessing

services for prevention and better management of asthma, COPD and support to quit smoking.

This in turn meant a comprehensive and considered consumer perspective was not provided to

service providers to influence practice

Engagement of settings (e.g. workplaces, local government, sports clubs) to support the health

of staff and/or consumers prevent and manage respiratory conditions

Engagement of primary care workers such as mental health workers

Increasing the supply of PR services and maintenance programs.

These are areas for further work into the future.

A focus on inequity

The NRP project was set up to focus on inequities. The northern Adelaide area is one of the more

disadvantaged areas in Australia meaning lower levels of health literacy, higher health needs, less

use of preventive health services, more risk factors including smoking and more social determinants


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impacting on overall health outcomes. Within the region the data for hospital use showed

disproportionate levels of admissions and ED attendances.

The NRP set out to assess the practicality of consciously applying what Michael Marmot calls

progressive universalism. This involves taking a universal approach to improving respiratory health

with enhanced support for high need communities - the three local areas: Playford Elizabeth,

Playford West Central and Salisbury Central.

This worked to some extent. Community activities did occur in this area but community engagement

was lower than planned. Primary care services (general practices and pharmacies) were offered

additional supports (training, resources, advice, tools, referral options, etc.) to provide good practice

respiratory care. The response to the supports offered was lower than hoped but capacity to have

done more intensive work to encourage take-up was limited with other initiatives and events

underway and being progressed at the same time. Outcomes were achieved where support was

provided including:

High uptake of education and training opportunities

Increased referrals

Screening

Best practice care

Improved clinical information systems

Measuring changes at the service level was difficult given less than optimal clinical information

systems in general practices. It was not possible to get a good baseline for interventions until after

NAML provided support with clinical coding and PenCAT assistance. There was no significant

impact on the hospital admissions or ED attendances from these locations.

Assessing the Partnership in the Northern Respiratory Partnership project

The underlying premise of the NRP was that more would be achieved by bringing together disparate

partners who have a role in respiratory health including tobacco control, but do not necessarily work

together, do not prioritise the northern Adelaide area for attention and do not maximise their limited

investment through collaboration. The intention was to minimise duplication and unconnected

strategies, while at the same time increasing gains achieved through enhanced cooperation,

collaboration and knowledge- and information-sharing. This would assist in developing a more

sustainable long term approach.

Partnerships allowed the project to implement actions and achieve outcomes that would not

otherwise have been possible. This is not new but bears repeating. All NRP partners remained

highly engaged in the NRP throughout the project.

The following facilitated the success of the partnership:

Active and continuous engagement by the project coordinator

Partner participation in scoping the project, overseeing the implementation and implementing

components

Having partners with clinical expertise involved in the planning of initiatives; this was very

valuable

Small amounts of funding to support activities


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A focus on win-win outcomes – positive outcomes for the work of the project as well as the

partner agencies, e.g. access to key people in the region which might otherwise have been

difficult for state or national organisations

Inclusion of partner organisations who can, through their own partners/members, drive change

(e.g. PSA, NRGPC)

Regular meetings of the PMC; this allowed members to remain connected. Arguably the

meetings could have been less frequent than monthly once established. Financial support for

interstate partners to have regular engagement with the project (e.g. 3-4 times per year) would

have been beneficial

Establishing a joint hospital-primary care committee. Bringing together these sectors on a

specific issue like respiratory health allowed good progress on initiatives, fostered relationships

and laid the groundwork for future partnerships.

Beyond the formal partners there was also the intention to develop partnerships with other sectors

and the community. This was less successful.

PROJECT INVESTMENT

The NRP received funding of $434,000 (plus GST) over two years. This funding both contributed to

NAML’s project support operational expenses and was supplemented by NAML funds (e.g. for the

evaluation). Approximate expenses are shown here.

Table 8.1 NRP budget expenditure

Expenses % of total budget Description

Project staffing 53 Project coordinator, advisor and contribution by the manager

Contracted projects 10 e.g. Asthma pharmacy referrals project, schools training, resource development

Expert advice 2 Payments to health professionals

Project activities 12 This covered events, training and workshop expenses

Project management support

23 This includes set-up, financial support, admin, IT, resource development, audit

Staffing is clearly the major component of the budget and the most important part of making the

project work.

NRP partners made a combined commitment of in-kind funding of $543,299. Although not

specifically costed, all partners felt that their actual contribution was considerably more. This

included their time and the time of members of their organisation, the resources they provided and

supports such as literature searches, review of documents, advice on data, hosting of meetings and

much more.


96

NAML and partners also supported the initiative by ensuring that wherever possible relevant

programs, services, projects and promotions were aligned to supplementing and complementing

this initiative.

PROJECT LEARNINGS

A focus on prevention across the continuum of care is sound but the more effort at the upstream

level the less the chance of achieving downstream indicators such as reduced admissions and

ED attendances. The NRP could have focused more strongly on tertiary prevention possibly

helping achieve the goal. However, the intention of the project was to intervene in multiple areas

and the pay-offs may take years to achieve, certainly more than the two-year timeframe of this

project. This tension is inherent in the approach and is likely to be a challenge in any project of

this scope

The project goal and targets under project objectives were set in the absence of a great deal of

evidence about what was likely to be feasible and achievable, and without a precedent to learn

from in terms of tackling the complex issues that surround asthma and COPD in our

communities. However, the aspirational goal and ambitious targets served as a key focus under

which the project plan was formulated

Progressing multiple strategies concurrently and balancing the opportunistic (e.g. a chance to

run a training program, support an event, promote the project) with the longer-term planned

agenda (longer term, more complex strategies) is difficult. Schedule in a major review every six

months where this is critically reviewed

Setting aside a reasonable amount of time for significant components of work, e.g. the PR

project whilst also progressing day-to-day activities

Things change as projects progress despite the clearest plans. The needs and directions of the

host agency need to be taken into account; staff may be difficult to recruit; in-kind support may

not eventuate; proposed actions (e.g. small grants) may prove to be inconsistent with agency

norms, etc.

Ensure all activities have sufficient lead-in time to allow for proper consideration/input by the

relevant project partners; this is also important for keeping the relationship strong and so

partners feel valued

Stability in the project staff is very important. It was beneficial having a project advisor role to

this project, adding expertise but also maintaining continuity

The focus was on the primary health care sector but this is large – there were over 50 general

practices and pharmacies in the priority areas alone, and allied health received little attention.

Engagement of pharmacies and practices, e.g. in the pharmacy initiatives and the general

practice respiratory clinic initiative required active solicitation by NAML staff. Time spent upfront

ensuring participating primary care agencies are fully committed would be time well spent

Training was a good way of reaching people but is time-intensive; had good attendance levels

albeit disappointing numbers of ‘Did Not Attends’ at some general practice education sessions

(but this is not peculiar to this project alone); and requires project coordinator follow-up of any

leads to maximise the benefits

Allow seed funding to support external providers to progress initiatives. A lot can be done with

relatively small amounts of funding

It takes time to build momentum – for many involved the NRP is just achieving this now. Three-

year timelines at least are required


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NEXT STEPS

This section provides information for decision makers about how to build on and improve the NRP

project and similar projects into the future.

NAML was the successful tenderer for the Adelaide Primary Health Network. It will work towards

ensuring that successful projects and activities across the region continue and are consistent across

metropolitan South Australia. This should include a focus on respiratory health.

Throughout the report suggested ways forward are identified and areas for further action are

included in the summary of achievements against objectives – see Appendix 9. The following

summary recommendations will inform future work in northern Adelaide, and may prove useful for

planning and implementation of similar projects:

Consolidate and expand the NRP approach to allow more time to test the intervention and

collect more data. This will help assess the merits of the intervention. A lot of work has been

done that could be translated more broadly across the metropolitan region

Continue to invest in the partnerships established, as well as overall project coordination efforts

– keeping relationships fertile and productive will have a big impact on project outcomes into the

future

The broad scope of the project was evidence-informed, but mitigated against achievement of all

outcomes by requiring action on too many fronts. Given the NRP experience of what is feasible,

identify the central action areas for sustained effort where the largest shift in outcomes can be

achieved

Maintain an (aspirational) goal of reducing hospital admissions and ED attendances as a driver

for the project but set project goals based around the secondary advantages that are now

known to be gained by a partnership focus on chronic disease prevention/management. Set

more defined, readily measured targets, in close collaboration with experts in the area

Invite providers to hear the results of this project and encourage participation in achieving the

goal in collaboration between primary and acute care. Ask for further ideas on how to achieve

changes

Continue to support improvements in general practice client information systems to enable

measures of effectiveness at the practice level

Continue the focus on inequities and target providers and consumers living in the high need

areas

Maintain a PMC as it was highly regarded by all involved and was effective and influential. The

evaluation suggests it is useful to find the right balance between a strategic management role

(managing the budget, focusing only on outcomes against the high level indicators, etc.) and a

more operational role. The former has less of a hands-on role and may mean less commitment

to the project whereas an operational role where there is considerable discussion of activities

can distract from the high-level oversight of the key project deliverables. What is important is

partner input with regard to: the overall project plan; decisions about which initiatives to pursue

and on where the resourcing/energy should be invested; keeping the host agency and all

partners accountable; brainstorming and planning function at the start of each initiative and then

can provide advice when troubleshooting is required; support with engaging others who can

contribute to the success of events/initiatives (e.g. guest presenters).

Tackle mental health and smoking in a concerted way – bring on new partners to assist and use

the NRP expertise in partnerships to build momentum. Apply consistent messages across the

continuum of care. Build on the connections made and become a leader in this area

Review the recommendations of the Aboriginal Tobacco Round Table and progress priorities


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Maintain a focus on seeking funding for an evaluation of a model of care to support smoke-free

pregnancies among Aboriginal women and their families

Have a focus on COPD exacerbation management with general practice and the hospitals. This

included the stepping up and down of medications and referrals back to GPs from hospital.

Explore potential for new services including Lungs in Action and PR programs in the community.

Look at use of private and community facilities, different models and providers, links with other

programs, e.g. chronic heart failure and, if feasible, support establishment of new services

including upskilling exercise programs to maintenance programs. Learn from Medicare Locals

that have made improvements, e.g. Sunshine Coast, Gold Coast, Western Sydney and

Mornington Peninsula

Focus on children and asthma – explore innovative ways to reach children in the area through a

NALHN / Asthma SA partnership, with support from the Northern Health Network.

Consumer consultation, engagement and awareness-raising on respiratory health issues is a

significant demand. Considerable thought needs to be given to this. Use the proposed Adelaide

Primary Health Network ‘Consumer and Carers’ Membership Consortium Group as a sounding

board for initiatives and to gain consumer perspectives.

Give early attention to fostering and supporting self-management and consumer education

programs.

The Northern Respiratory Partnership project set ambitious goals and has delivered a

comprehensive approach to promoting good respiratory health and preventing, intervening early

and better managing asthma and COPD. It is an exemplar project that has achieved a wide range

of positive outcomes.


Appendix 1 Northern Respiratory Partnership partner organisations and expected

contribution

NRP partner organisations Expected contribution


Project auspice, leadership, governance, coordination and facilitation. Able to ensure strong linkages with primary health care. Identified respiratory health as a high need in the region

Northern Adelaide Local Health Network

Respiratory health was a key priority for NALHN given high rates of preventable admissions. Had begun working with NAML to ensure joint approaches. Many NALHN staff would contribute to respiratory health, e.g. hospital staff, Aboriginal Health providers, community health staff, etc.)

Drug and Alcohol Services South Australia

DASSA is the lead SA agency for policies and programs related to smoking prevention and was supportive of partnership approaches to help prevent smoking and assist people to quit

Asthma Foundation SA Asthma SA is the peak body for asthma in SA providing individual advice, community education and professional support and training services as well as clinical and patient resources


LFA is a national organisation with South Australian members including clinicians. They would provide advice on early identification, screening, diagnosis and evidence-based management of COPD, as well as access to clinical and patient resources

Pharmaceutical Society of Australia (SA/NT Branch)

Pharmacists and pharmacies are key players in the effective management of chronic conditions. The PSA would provide strategic and practical support to this initiative including the perspective of community pharmacy

Cancer Council SA - Quitline

Not a formal partner originally though involved in contributing to the proposal, Quitline would provide practical quit support to those wanting to quit as well as training of health professionals. Quitline joined as a NRP project partner in mid-2014

Northern Region GP Council

The NRGPC is the regional body that supports GPs in the region and provides representation on issues of importance to general practice. As the major providers of primary care it was essential to have the perspective of practitioners into the NRP


Appendix 2 NRP project plan March 2014 (revised from April 2013)


Northern Respiratory Partnership

Project Plan

March 2013

(revised April 2014)


Attachment related to item 2.1 Objectives, Key Activities and Timeframes

Project Goal: To reduce avoidable hospital admissions and emergency department attendances by 10% for COPD and asthma in

the Northern Adelaide Medicare Local region by 31 March 2015

Objective one (primary prevention)

To minimise or prevent the occurrence of COPD and asthma for the whole NAML population and groups at risk an specifically:

o to reduce overall smoking rates in NAML residents by 2% and particularly in those most at risk

o to increase health literacy about copd and asthma

o to reduce risk conditions for copd and asthma through community settings

Key activities & Partner involvement Perf indicators (P) and

outcome (O) measures Data sources Time frames

1.1 Smoking prevention activities

include:

o Community education re smoking to

the whole population and specifically

to those with asthma or COPD (and

their families), and high risk groups

o Develop and encourage anti-

smoking policies e.g. health

services, public spaces

o Assist individuals to quit smoking

(see 2.1 below)

Communications strategy for

tobacco (P)

Examples of enhanced smoking

promotions and policies general

and specific for at risk groups

(P)

Smoking rates for NAML

population monitored

(attribution not possible)

Quit smoking interventions for

those with mental illness and for

ATSI populations (not possible

Key informants re smoking

policies

Health Omnibus survey

data: Baseline smoking in

2012 was 17.5% in NAML

Round Table report

Ongoing throughout project


o Support for more coordinated

approach to quit services/tools for

ATSI

(DASSA is lead partner but all will

support)

to measure smoking rates at

regional level) (P)

Outcomes of Aboriginal

Tobacco Round Table (P)

Level of engagement of AHWs

in the project (P)

Practice data will show

smoking for those with

COPD and asthma – see

2.1. Use common smoking

questions if individual

assessment is undertaken

Medicare Locals National

performance indicator:

prevalence of smoking

(6.3.5.4)

April 2014 (Round Table) plus

actions over 12 months

Focus group with AHWs to

assess their engagement in

respiratory health early in

project and at the end

1.2 Increasing Health Literacy

activities include:

o Identifying consumer barriers to

COPD and asthma prevention

behaviour self-management and

preventive service use

o Monitor availability and suitability of

respiratory information resources

(clear, accurate, low literacy,

culturally appropriate, availability of

services etc) for consumers in a

coordinated way

o Delivering awareness events and

promotions

Consultation mechanisms have

been implemented and reported

(P)

Strategies used have enabled

participation by groups where

literacy levels and access to

services would usually exclude

participation (O)

Commentary on resources (P)

Evidence of a more coordinated

approach (P)

NRP document on

consumer views re

respiratory health and the

processes used

Project log of activities

Community consultation on

smoking by NAML Dec 2013

Consultation with community

via 2 focus groups in mid 2014

Consumer resources monitoring

(ongoing)


o Increasing the availability of

consumer education sessions/self-

management programs/promotion of

help lines

Partners will be the primary people to

provide resources and conduct

community education events. Consumer

barriers assessment work will be

undertaken by the Coordinator with

other NAML staff. Through the NRP we

expect there will be an increased focus

on the NAML region by all partners. Also

their existing engagement mechanisms

can be used to collect information;

innovative approaches will be explored

Examples of good practice and

innovative universal and

targeted community awareness

activities and information (P)

Help line usage improves

asthma knowledge and

management (O)

NRP-related services and

activities are more responsive to

consumer knowledge, attitudes

and behaviours (O)

Increased health literacy about

COPD and asthma prevention

and management (O)

Project log of activities

Before and after survey of

Asthma SA users (from

pharmacy)

Examples of services

changes in response to

consumer needs

Case study through Wave

initiative – see 2.1 below))

Key events in 2014 and 2015

e.g. World No Tobacco Day

May, Asthma Awareness week

in Sept, COPD Awareness day

in Nov)

Opportunistic awareness raising

Consumer education sessions

to be determined

1.3 Reducing Risk Conditions

activities include:

o Deliver education interventions in

key settings (child care, schools)

Training session participants:

have increased knowledge and

skills to respond to an asthma or

COPD emergency; are aware of

the risks of respiratory illness;

Before and after surveys

for training sessions

Baseline of existing training and

potential recipients by Nov 13

Training ongoing over 16

months


o Explore options to undertake training

in workplaces, aged care, sporting

clubs and local government)

o Defining and supporting respiratory

friendly practices and programs in

partnership with local governments

(6)

(Partners: Asthma SA already provides

training on a user pays basis to these

settings but with expected additional

demand, additional funding will be

provided to support additional activity in

the NAML region, prioritising hot spot

locations)

support self-management;

undertake appropriate testing

and promote healthy

environments (O)

80% coverage of children’s

services and schools in priority

locations and increase in the

number trained in other areas.

Six workplaces trained. (P)

Respiratory health related

activities included into the Public

Health Plans (P)

Asthma SA provide

baseline coverage of

training in NAML settings

(schools, clubs etc) and

numbers trained

Local government plans (if

completed)

Local government approached

to consider respiratory issues –

Mid 2014

Objective two (secondary prevention)

To reduce or stop further damage from COPD and asthma through increased early identification and effective management of

COPD and asthma for all residents and particularly those areas/groups most at risk

2.1 Provide information, advice and

support to primary care providers –

beginning with pharmacies and general

practice but including NGOs, allied

health, AHWs – on good practice for

care of people at risk of and with COPD

All pharmacies and GPs

provided advice on NRP,

smoking, asthma and COPD

good practice (P)

(re 2.2) 40% of practices in

identified priority locations

Project reports

Project reports

At each project report

Pharmacy in May and August

2014


and asthma and wishing to quit. This

includes:

o Best practice technical guidelines

o Practice tools information e.g.

register systems, IT

o information on specific service

components (e.g. spirometry testing,

home oxygen, pulmonary rehab etc)

o Referral pathway guidelines

(including proposed specialist

multidisciplinary respiratory service,

home care supports etc)

o Funding models

o Roles and contributions of different

players e.g. GPs, practice nurses,

pharmacy, allied health/

rehab/physical activity programs,

NGO support services, nurse led

clinics

o Management of specific conditions

e.g. asthma during pregnancy,

managing those with mental illness

and respiratory conditions, managing

co-morbidity

o Prevention information including brief

interventions

participate in practice

improvement initiatives including

Improvement Foundation Wave

initiative (P)

Participating practices show

evidence of practice

improvement (as in 2.1) e.g.

registers, referrals (to Asthma

SA, Quitline, other), information

provision etc (P)

Improved outcomes for

consumers (O) and appropriate

health service usage (O)

Pharmacies: see detailed plan

but covering referrals, consumer

advice and potentially screening

(P)

Pharmacy and GP sub-

project reports

o Mystery shopper and

accreditation process

(pharmacy)

o Referral numbers from

Asthma SA and Quitline

o Pharmacy accreditation

reviews

o Wave project results

o Information from

general practices

Case study of several

clients in primary care

practices

In priority locations where

registers are established

detailed information should

be available e.g.: no. coded

with COPD, smoking rates

for those with COPD,

assessment rates,

spirometry recorded,

vaccinations (flu,

pneumococcal) given etc.

GP wave in Oct 2014

Priority locations will be

identified by end September

2013

Practice improvement support

for priority locations will be in

late 2013, 2014/early 2015

Reductions in admissions and

attendances will be measured

at March 31 2015


2.2 Provide intensive support for

practices and services in priority

locations to implement changes in line

with guidelines and identify opportunities

and barriers to improving services for

those with high needs

(Partners will nominate representatives

and other experts to participate in this

process and most already have existing

guidelines though not uniformly

agreed/adopted; the NALHN has crucial

role in ensuring clinicians participate in

and support this initiative)

Reductions in avoidable

admissions and ED attendances

(O)

National reporting indicator

6.3.1.3 % asthma patients

with a written asthma plan

(not yet reported so may

not be available)

Survey/sample audit of

GPs and pharmacies

(mechanism to be advised

and to be integrated with

other NAML liaison work)

2.3 Identify training needs, options

available and promote and support

training for primary care practitioners

(e.g. GP, nurses, pharmacists and

pharmacy assistants, community

workers etc) beginning with priority

locations and those serving groups at

risk (see 4.3)

Build practitioner skills to assist

consumers (especially those with high

needs) self manage their condition/s

Some Partners Lung Foundation,

Quitline and Asthma SA all provide

All participating agencies (2.2)

have some staff trained (P)

Evidence of staff training in Quit

skills (P)

Increased practitioner efficacy

for supporting high need

individuals and groups (P)

Numbers participating in

training (face to face and

on-line – e.g. COPD in

pharmacies; seminars,

Wave participation)

Training needs and options

identified continuously through

consultations

Training support provided Aug

2013-early 2015


training; additional funding will support

high need communities; all will

contribute to ongoing review; training will

be subsidised for others e.g. through

APCC

2.4 Contribute advice on gaps in COPD

and asthma secondary prevention

services/workforce in the NAML region

and options to meet these needs to

NALHN and NAML. This might include

need for Specialist Respiratory GP,

nurse practitioners etc

(All partners will be encouraged to

contribute and discussions will be

facilitated to ensure this occurs)

Evidence of advice provided (P)

Intelligence collected

during the initiative and

documented by the NRP

and Management

Committee

Ongoing throughout the project

2.5 Contribute consumer views

regarding COPD and asthma prevention

where possible to inform good practice

care (see 1.2 above)

Examples of practice

responsiveness to consumer

concerns (P)

Increased use of health literacy

materials e.g. Ask Me 3 (P)

Project reports ongoing


Objective 3 (tertiary prevention)

To rehabilitate as far as possible and to reduce the likelihood of exacerbations or relapses for those with COPD and asthma.

Note effective implementation of Objective 2 also supports tertiary prevention.

3.1 Ensure hospital (in patients and ED)

responses support good management

(information, referrals, coordinated care

etc – clinical care not in scope) of

patients using the service and build

effective primary care – acute care

collaboration

3.2 Maximise use of hospital avoidance

services, especially pulmonary rehab for

those with complex needs

NRP participants report

pathways are clear and being

used (P)

Reductions in avoidable

admissions and ED attendances

(O)

Evaluation reports

Main outcome measure via

data

Hospital committee established

Jan 2014 and directions

determined and implemented in

2014-15

Objective four

To establish a comprehensive coordinated whole of community approach to the prevention of COPD and asthma


4.1 Appoint a project coordinator to:

o Provide high level project leadership

throughout the 2 years

o Plan the initiative and lead the

implementation and document the

model

o Develop and maintain effective

partnerships and commitment with

all key players including consumers

o identify health economics expertise

o liaise with ANPHA re evaluation

(Key partners to be on interview

committee, project committee and liaise

regularly)

Coordinator appointed (P)

Coordinator successful in

leading change for results (P)

Key partners maintain

involvement throughout project

(P)

New partnerships are developed

and there are tangible examples

of a comprehensive coordinated

approach (O)

Health economics advice sought

(P)

Project evaluation

Partnership evaluation tool

Cost data from services

plus cost of intervention

Project coordinator commences

mid-May and leads project until

conclusion (31 May 2015)

Meet with health economics

academic Jan 14

Determine project by mid-2014

4.2 Undertake a stocktake of current

COPD and asthma related services,

guidelines, programs, tools, workforce

and practices in the NAML region to

inform gaps, overlaps and opportunities

(Project partners to help define scope,

assist with contacts, provide information,

review and advise on use)

Stocktake undertaken at

beginning (P) and end of project

with evidence of improved

service provision across the

continuum (O)

Stocktake data from

partners, web, research

Assessment against ideal

service provision

By end of June but will be

maintained and updated

throughout


4.3 Prepare comprehensive data report

covering health behaviours, primary

care, hospital, pharmaceutical use etc

by location (at the smallest level

possible), demographics including socio-

economic status. Identify need for other

data.

Use the data to inform program and

service priorities particularly where to

reach the vulnerable groups. Identify

locations of high need – e.g. high

utilisation of ED, hospital services, high

rates of COPD, asthma

(Partners will provide and help analyse

data e.g. NAML and LHN planning team

will lead, partners will review analysis)

Data report available and

distributed (P)

Evidence that data used to

inform all key players in NAML

region re importance of

respiratory health, prevention

opportunities and to set priorities

and priority locations for action

(O)

Evaluation report

Stakeholder interviews

Data report completed by end

June 2013

Update and extend as new data

is available e.g. GP practice

data


4.4 Develop partnerships for solution

focussed results

Engage with key players to gain

commitment to concerted approach to

NRP, examine, data and

service/program gaps and identify

priorities for action

Develop best mechanisms for

engagement

(Partners are critical champions

responsible for assisting in successful

engagement)

Documentation of all key players

re respiratory health and their

involvement (P)

Evidence of increased

communications and

collaboration between all service

providers, engagement and

commitment e.g. forums well

attended, individual and group

meetings with outcomes,

champions identified (P)

ANPHA evaluation shows

extensive commitment to

coordinated and comprehensive

approach and expectation of

sustainability (O)

Coordinator to provide

documents

Agreed partnership tools

used at beginning and end

of project

Evaluator to review and

interview key stakeholders

Forums conducted periodically

around key education,

consultation and initiative

opportunities


Appendix 3 Information sheet to general practices on NRP opportunities


Appendix 4 Asthma Assist referral form


Appendix 5 Hospital Working Group on NALHN responses to asthma and COPD

Aim

To identify in-hospital responses to preventing and better managing COPD and asthma ED

attendances and admissions

Goal

To contribute to best practice care for those at risk of or with diagnosed COPD or asthma across

the continuum of care

To contribute to comprehensive and coordinated approach to respiratory health in the NAML

region, especially for those most at risk.

Tasks

Scope issues of concern and opportunities for practice improvement e.g. referrals to NGOs for

patient follow up; improved information on/referrals to pulmonary rehabilitation;

information/guidance for GPs and practice nurses at discharge and before; availability of

alternative pathways to ED e.g. rapid assessment; need for and availability of psychological

services; use of action plans; training re devices, access to training; care pathways etc

Determine priorities for action in relation to:

o primary health care – ED and inpatient interface

o internal hospital issues

o priority populations e.g. those with frequent admissions, those with mental health problems

Assign roles, timeframes and measures.

Working group members included NALHN medical, nursing and pharmacy representatives covering

both ED and inpatients and asthma and COPD as well as the Director of Primary Health Care

Strategy and a general practitioner (both NRP PMC members). The NRP project coordinator, Health

Integration Manager and the project advisor also attended.


Appendix 6 Issues addressed by the NRP Hospital Working Group – a summary

Issue What strategies have been implemented?

Objective 1 Primary prevention

Smoking prevention

Develop and encourage

anti-smoking policies

NALHN is compliant with the SA Health Smoke-free health

services policy. A 2015 meeting between the Quitline, NAML,

DASSA and NALHN identified further actions that will be taken

to promote quitting to staff and patients and assist people to quit.

Increase health literacy

Deliver awareness

events and promotions

Increase consumer

education/self-

management/promotion

of helplines

NALHN has held displays on World COPD Day and a morning

tea

A Quitline display was held at the LMH for the 2015 World No

Tobacco Day

Breathless in the North (self-named) is a patient-driven support

group; the Working Group supported this group.

Objective 2 secondary prevention - primary health care

Provide information, advice

and support to primary

care providers

Provide intensive support

to practices and services in

priority locations

There is regular liaison with primary care providers in

relation to patients, e.g. through the Asthma Clinic at GP

Plus Elizabeth

The five practices with respiratory clinics and other practices

involved have agreed that NALHN dedicated respiratory unit

staff can begin advising patients who do not have a treating

GP of the availability of these clinics. A patient flyer that

contains details of all five practices will be put up in

Respiratory OPD at the Lyell McEwin and Modbury. This

helps address an area of concern that a number of people

attend ED or are admitted with respiratory problems and

don’t have a regular GP.

The potential for respiratory specialists to visit practices with

Respiratory Clinics is being explored

The issue of links in relation to arterial blood gas (ABG)

monitoring being performed out of hospital (by practice

nurses or through private pathology services) was explored.

The NALHN respiratory nurse will support the practice

nurses running the GPRCs by providing information to them

about the home oxygen program via a resource pack and

also possibly a half-hour workshop

Mental health problems are common for those with chronic

respiratory conditions and there was concern at the limited low

cost options for mental health support. NALHN staff were



advised of the NAML Living Well with Serious Illness service for

people living with progressive life-limiting illness and

experiencing anxiety or depression. Referral procedures have

been clarified and the program is being promoted to hospital

staff (via brochure, word-of-mouth).

Protocols for referring clients to NALHN respiratory specialists is

under consideration

Objective 3 tertiary prevention - acute care

Ensure hospital responses

… build effective primary

care – acute care

collaboration

Maximise use of hospital

avoidance services…

A ‘24/7 phone helpline’ has been made available to the five

practices with General Practice Respiratory Clinics in relation to

patients with respiratory conditions. GPs can contact the “on call

Respiratory Consultant” at the hospital if they require advice on

respiratory patients. This will help support primary care

management of people who might be at risk of admission to

hospital.

Ensure hospital responses

… build effective primary

care – acute care

collaboration


avoidance services…

The five practices with General Practice Respiratory Clinics

have been given priority to refer patients to the Medical Quick

Access clinics established by NALHN. Senior NALHN staff are

visiting practices to provide information on the clinics which are

designed to see patients at risk of admission quickly to ensure a

timely response to the health problem in collaboration with

primary care services.

Ensure hospital (inpatients

and ED) responses support

good management

(information, referrals,

coordinated care, etc.) of

patients using the

service…

In September 2014 NALHN adopted the statewide Paediatric

Asthma guidelines for use across the service. The guidelines

include an Asthma Action Plan for use in the hospital. Uniform

implementation of the guidelines across the health service is

being supported and other guidelines are under review. A

statewide group is reviewing consistency with the National

Asthma Guidelines.

The ‘Pink card’ (instructions on discharge from inpatients–

COPD action plan to take to GP) was reviewed for content and

updated in line with latest COPD guidelines. This is being rolled

out across NALHN.

People leaving ED with COPD (only around 10% of COPD

patients) get an Emergency Pack of antibiotics. On advice from

NALHN Pharmacy, the standard antibiotic has been formalised.

A letter is sent to GP following discharge and patients are

encouraged to see their GP asap




avoidance services,

especially pulmonary

rehabilitation for those with

complex needs

The PR Working Group (sub-group of the Hospital WG) has

progressed a number of strategies related to mapping current

supply of services and promoting the importance of PR to

general practice and other stakeholders.

SA Health in-principle approval was obtained for NALHN staff to

provide mentoring to private PR providers to set-up Lungs in

Action and PR programs in the community

Frequent hospital attenders are fast tracked into PR. Further

work is required

A Clinical Practice Consultant, Respiratory Chronic Disease,

NALHN and the NRP Project Coordinator attended a 2-day

workshop conducted by the Health Roundtable on Reducing

Readmissions for COPD through collaboration with primary

care. This was an excellent opportunity and summaries are

available.

Objective 4 A

comprehensive

coordinated whole of

community approach to

the prevention of COPD

and asthma

The Hospital Working Group facilitated many connections with the

NRP and project activities.


Appendix 7 Maps showing COPD prevalence and pulmonary rehabilitation services


Appendix 8 Evaluation questions for NRP partners

1. What impact do you think your organisation’s involvement had on the outcomes of

the project?

2. Have there been changes in practice or service provision in the NAML region as a

result of the partnership?

3. What if any were the benefits for your agency? Was this shared with others in the

agency?

4. What were the negatives if any of being involved in the NRP?

5. Were there any unintended effects of the partnership – positive or negative?

6. With the benefit of hindsight what should the NRP have done differently in relation to:

The project as a whole

Your involvement as a partner?

7. What would you do differently if you were approached to be involved in a similar

project in the future?

8. The application indicated you would make an in-kind contribution of $7333. Is this

close to what occurred?


Appendix 9 Summary of achievements against NRP process and outcome indicators

Objectives and key activities Indicators and Results

Process and outcome indicators

Summary rating and comment

Objective 1

To reduce overall smoking rates in NAML residents by 2% and particularly those groups at risk

Daily smoking – NAML region

2012 – 20.1%

2014 – 15.5%

A 4.6% fall

Achieved

(local action potentially contributed to positive results)

Objective 1.1 Smoking prevention activities

1.1.1 Community education re smoking to the whole population and specifically to those with asthma or COPD (and their families), and high risk groups

Examples of enhanced smoking promotions general and specific for at risk groups

Information on smoking at 8 community events

Moderate implementation in general; limited engagement of others; limited reach

Communications strategy Internal process indicator only

1.1.2 Develop and encourage anti-smoking policies e.g. health services, public spaces

Examples of enhanced smoking policies general and specific for at risk groups Limited implementation. Focus for future activity

1.1.3 Assist individuals to quit smoking (relates also to 2.1)

Quit smoking interventions for those with mental illness and for ATSI populations (see below)

Limited implementation. Focus for future activity

For population as a whole:

5 specific quit focused training events

Nearly 100 service providers reached with positive evaluation

Electronic Quitline referral templates installed in 17 18.3% of general practices

Achieved


Information/resources provided for 83 pharmacies and 93 general practices

Multiple general practice visits

Quit line calls from NAML region show 32 additional calls over a 3 month period from PHC organisations

1.1.4 Support for more coordinated approach to quit services/tools for ATSI

Outcomes of Aboriginal Tobacco Round Table

Limited implementation. Focus for future activity

Level of engagement of AHWs in the project Moderate achievement - could be more extensive and systemic

Objective 1.2

To increase health literacy about COPD and asthma

1.2.1 Identifying consumer barriers to COPD and asthma prevention behaviour self-management and preventive service use

Consultation mechanisms have been implemented and reported (P)

Limited implementation

Strategies used have enabled participation by groups where literacy levels and access to services would usually exclude participation (O)

Limited achievement

NRP-related services and activities are more responsive to consumer knowledge, attitudes and behaviours (O)

Not measured due to low implementation

1.2.2 Monitor availability and suitability of respiratory information resources (clear, accurate, low literacy, culturally appropriate, availability of services etc.) for consumers in a coordinated way

Commentary on resources (P)

Limited achievement

Evidence of a more coordinated approach (to resources)(P) Achieved


1.2.3 Delivering awareness events and promotions

Examples of good practice and innovative universal and targeted community awareness activities and information (P)

Moderate achievement

1.2.4 Increasing the availability of consumer education sessions/self-management programs/promotion of help lines

Help line usage improves asthma knowledge and management (O) TBC

Increased health literacy about COPD and Asthma prevention and management (O)

Not measured due to limited implementation

Objective 1.3 to reduce risk conditions for COPD and asthma through community settings

1.3.1 Deliver education interventions in key settings (child care, schools)

Training session participants: have increased knowledge and skills to respond to an asthma or COPD emergency; are aware of the risks of respiratory illness; support self-management; undertake appropriate testing and promote healthy environments (O)

In education settings – asthma focus:

80% coverage of children’s services and schools in priority locations and increase in the number trained in other areas.

74% achieved in education settings in priority areas. 23% of sites trained in non-priority areas

Achieved

Close to achieved

Achieved

1.3.2 Explore options to undertake training in workplaces, aged care, sporting clubs and local government

Six workplaces trained. (P) 5 trained (asthma and COPD) Close to achieved

1.3.3 Defining and supporting respiratory friendly practices and programs in partnership with local governments (6)

Respiratory health related activities included into the Public Health Plans (P)

Not achieved


Objective 2

To reduce or stop further damage from COPD and asthma through increased early identification and effective management of COPD and asthma for all residents and particularly those areas/groups most at risk

Objective 2.1 Information, advice and support to primary care providers

Objective 2.2 Provide intensive support for practices and services in priority locations

All pharmacies and GPs provided advice on NRP, smoking, asthma and COPD good practice (P)

Letters, newsletters, education events, visits

(re 2.2) 40% of practices in identified priority locations participate in practice improvement initiatives including Improvement Foundation Wave initiative (P)

An average of 35% of pharmacy and general practices in priority areas participated in one or more NRP activities; this figure was 30.5% across the region

Participating practices show evidence of practice improvement (as in 2.1) e.g. registers, referrals (to Asthma SA, Quitline, other), information provision etc. (P)

QIP practices had significant improvements

GP survey not conducted to assess change as not sufficient reach

Pharmacies: see detailed plan but covering referrals, consumer advice and potentially screening (P)

Mystery shopper not progressed

165 pharmacy referrals to Asthma Assist infoline

Quitline calls – see 1.1

Pharmacy accreditation points awarded to all 8 pharmacies (11 pharmacists)

COPD screening – not significant numbers

Achieved

Focus for further engagement

Not achieved though good progress made.

Achieved

Not undertaken

Achieved good progress


Improved outcomes for consumers (O) and appropriate health service usage (O)

Only one case study of a consumer

Reductions in avoidable hospital admissions and ED attendances (O)

Not measured as no intervention. Focus for future activity

Not achieved - see chapter 3

Objective 2.3 Identify training needs, options available and promote and support training for primary care Build practitioner skills to assist consumers (especially those with high needs) self manage their condition

All participating agencies (2.2) have some staff trained (P)

Training provided to 170 individuals with positive evaluations

Evidence of staff training in Quit skills (P)

53 staff trained

Increased practitioner efficacy for supporting high need individuals and groups (P)

Not addressed or measured

Achieved

Achieved and more work underway

Not achieved – a focus for future activity

Objective 2.4 Contribute advice on gaps in COPD and asthma secondary prevention services/workforce in the NAML region and options to meet these

Evidence of advice provided (P)

Gaps identified during the project and addressed in part, e.g. via Hospital Working Group but not collated

Partial achievement

Objective 2.5 Contribute consumer views regarding COPD and Asthma prevention where possible to inform good practice care (see 1.2 above)

Examples of practice responsiveness to consumer concerns (P)

Not addressed

Increased use of health literacy materials e.g. Ask Me 3 (P)

Not addressed

Not achieved

Not achieved

Focus for future activity


Objective 3

To rehabilitate as far as possible and to reduce the likelihood of exacerbations or relapses for those with COPD and Asthma

Objective 3.1 Ensure hospital (in patients and ED) responses support good management (information, referrals, coordinated care, etc. – clinical care not in scope) of patients using the service and build effective primary care – acute care collaboration

NRP participants report pathways are clear and being used (P)

Good feedback from Hospital Working Group with positive examples of action around support for, and linkages with, primary health care, mental health services and guidelines.

Reductions in avoidable admissions and ED attendances (O) See Chapter 3

Achieved

Focus for further activity

Not achieved

Objective 3.2 Maximise use of hospital avoidance services, especially pulmonary rehab for those with complex needs

NRP participants report pathways are clear and being used (P)

Information on services provided and plans for further action.

Limited implementation but much groundwork achieved for next steps. Focus for future activity

Objective 4

To establish a comprehensive coordinated whole of community approach to the prevention of COPD and asthma

Objective 4.1 Appoint a project coordinator

4.1.1 Provide high level project leadership throughout the 2 years

Coordinator appointed (P)

Three project coordinators were appointed over the two year period.

Achieved

4.1.2 Plan the initiative and lead the implementation and document the model

Coordinator successful in leading change for results (P)

Significant project achievements given large project agenda

Achieved

4.1.3 Develop and maintain effective partnerships and commitment with all key players including consumers

Key partners maintain involvement throughout project (P)

New partnerships are developed and there are tangible examples of a comprehensive coordinated approach (O)

Substantial and continuous partner involvement throughout the project. Partnerships tool result XXX; high attendance at PMC; positive feedback

Achieved


4.1.4 Identify health economics expertise Health economics advice sought (P)

Initial discussions held but complexity was too great for time frame and capacity

Not implemented

4.1.5 Liaise with ANPHA re evaluation Reports were prepared and submitted as required by the contract. Extensive liaison with ANPHA prior to closure.

Achieved

Objective 4.2 Undertake a stocktake of current COPD and asthma related services, guidelines, programs, tools, workforce and practices in the NAML region to inform gaps, overlaps and opportunities

Stocktake undertaken at beginning (P) and end of project with evidence of improved service provision across the continuum (O)

Some service improvements

Partly achieved

Objective 4.3 Prepare comprehensive data report; use the data to inform program and service priorities particularly where to reach the vulnerable groups

Data report available and distributed (P)

The report was reviewed by the PMC

Evidence that data used to inform all key players in NAML region re importance of respiratory health, prevention opportunities and to set priorities and priority locations for action (O)

Achieved

Achieved

Objective 4.4 Develop partnerships for solution focussed results

Engage with key players to gain commitment to concerted approach to NRP, examine data and service/program gaps and identify priorities for action

Documentation of all key players re respiratory health and their involvement (P)

Final report documents role of key partners in the NRP

Evidence of increased communications and collaboration between all service providers, engagement and commitment, e.g. forums well attended, individual and group meetings with outcomes, champions identified (P)

Evaluation shows evidence.

ANPHA evaluation shows extensive commitment to coordinated and comprehensive approach and expectation of sustainability (O)

ANPHA evaluation not undertaken. Evaluation shows achievement of this outcome

Achieved

Achieved

Achieved. Focus for further activity


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2 Toelle B, Xuan W, Bird T, Abramson M, Burton D, Hunter M, Johns D, Maguire G, Wood-Baker R, Marks G. COPD in the Australian burden of lung disease (BOLD) study. Respirology 2011;16 (Suppl 1):12 cited on the Lung Foundation Australia website - http://lungfoundation.com.au/health-professionals/clinical-resources/copd/copd-the-statistics/

3 Australian Institute of Health and Welfare (AIHW). Australia’s health 2014, Australia’s health series no. 14. Cat no. AUS 178. Canberra. AIHW 2014

4 AIHW Chronic diseases summary. Available from http://www.aihw.gov.au/chronic-diseases-summary/

5 Lung Foundation Australia. COPD Information [online]. Available from: http://www.lungfoundation.com.au/lung-information/copd/

6 Public Health Information Development Unit. Social Health Atlas of Australia Data by Medicare Locals Published 2014: December release. University of Adelaide. Available from: adelaide.edu.au/phidu/maps-data/medicare-local-portal/ December 2014

7 Australian Centre for Asthma Monitoring. Asthma in Australia 2011. AIHW Asthma Series no. 4. Cat. No. ACM 22. Canberra: AIHW, 2011

8 AIHW How many people die from asthma? Available from: http://www.aihw.gov.au/asthma/deaths/

9 National Asthma Council of Australia. Inhaler technique in adults with asthma or COPD. Available from: http://www.nationalasthma.org.au/uploads/publication/inhaler-technique-in-adults-with-asthma-or-copd.pdf

10 Asthma Australia. Statistics. Available at: http://www.asthmaaustralia.org.au/Statistics.aspx

11 Public Health Information Development Unit. Social Health Atlas of Australia Data by Medicare Locals Published 2014:December release. University of Adelaide. Available from: adelaide.edu.au/phidu/maps-data/medicare-local-portal/ December 2014

12 Lung Foundation Australia. Lung disease in Australia. Available from http://lungfoundation.com.au/general-information/statistics/

13 AIHW How many people have an asthma action plan? Available from: http://www.aihw.gov.au/asthma/action-plan/

14 Lung Foundation Australia. Indigenous. Available from http://lungfoundation.com.au/patient-area/indigenous/

15 Asthma Australia. Statistics. Available at: http://www.asthmaaustralia.org.au/Statistics.aspx

16 SA Health. Primary Prevention Plan 2011-2016. Available from: http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/south+australias+health+care+plan/priority+areas+of+the+south+australias+health+care+plan/primary+prevention+plan+2011+-+2016

17 Marmot M. Fair society healthy lives. The Marmot Review: strategic review of health inequalities in England post-2010. 2010. Available at: http://www.ucl.ac.uk/gheg/marmotreview

18 SA Health Primary Prevention Plan 2011-2016. Adelaide 2011

19 National Public Health Partnership. Preventing chronic disease: A strategic framework. NPHP. Melbourne 2001

20 Nutbeam D. Building health literacy in Australia. Med J Aust 2009; 191(10):525–526

21 Katterl R, Anikeeva O et al. Potentially avoidable hospitalisations in Australia: Causes for hospitalisations and primary health care interventions. PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research & Information Service 2012.

22 AIHW 2013. Geographic distribution of asthma and chronic obstructive pulmonary disease hospitalisations in Australia, 2007–08 to 2009–10. Cat. no. ACM 26. Canberra: AIHW.

23 SA Health Emergency Department Data Collection (EDDC) unit record level from Central Data Warehouse; Admitted activity collection (ISAAC extracted from the Central Data Warehouse unit record level data, public and private hospital where principal diagnosis is CD10-AM 7th edition). J41-J47, J20; patient’s usual residence is in NAML

24 Public Health Information Development Unit (PHIDU). Medicare Local Atlas 2012. Adelaide: PHIDU, The University of

25 AIHW Australia’s Health 2014 Chronic respiratory conditions. Available from http://www.aihw.gov.au/australias-health/2014/ill-health/#t9

26 Asthma Foundation WA Asthma and smoking. Available from http://www.asthmawa.org.au/About-Asthma/Asthma-Factsheets/Asthma-and-Smoking/

27 AIHW Tobacco smoking Available from http://www.aihw.gov.au/risk-factors-tobacco-smoking/

28 Scollo MM & Winstanley MH. Tobacco in Australia: Facts and Issue. 3rd Edition. Melbourne: Cancer Council Victoria, 2008.

29 Department of Health Tobacco key facts and figures. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco-kff

30 University of Adelaide Population Research and Outcomes Studies. Health Omnibus Surveys. Available from https://health.adelaide.edu.au/pros/data/hos/

31 National Health Performance Authority Healthy Communities. In Focus Healthy Communities. Tobacco smoking rates across Australia, 2011-12

32 National Health Performance Authority Healthy Communities: Tobacco smoking rates across Australia, 2011–12 Technical Note

http://lungfoundation.com.au/patient-area/lung-diseases/copd/

http://www.lungfoundation.com.au/lung-information/copd/

http://www.adelaide.edu.au/phidu/maps-data/medicare-local-portal/

http://www.adelaide.edu.au/phidu/maps-data/medicare-local-portal/

http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/south+australias+health+care+plan/priority+areas+of+the+south+australias+health+care+plan/primary+prevention+plan+2011+-+2016

http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/south+australias+health+care+plan/priority+areas+of+the+south+australias+health+care+plan/primary+prevention+plan+2011+-+2016

http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco-kff

https://health.adelaide.edu.au/pros/data/hos/


Data were sourced from the ABS Australian Health Survey 2011-13 where adults were asked whether they currently smoked at least once per day. Available from http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_Tobacco_Smoking_Rates_Technical_Note_October_2013.pdf

33 Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey 2012-13

34 COAG Reform Council 2010, National Indigenous Reform Agreement: Baseline performance report for 2008–09 (Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Social Survey (NATSISS) 2008

35 Tobacco in Australia Facts and Issues. 7.12 Smoking and mental health. Available from http://www.tobaccoinaustralia.org.au/7-12-smoking-and-mental-health

36 SA Health. Smoke-free Policy Directive. 31 May 2010 Available at http://www.health.sa.gov.au/Portals/0/SmokefreeDirective-comms-sahealth-2100504.pdf

37 Royal Australian College of General Practitioners. Supporting smoking cessation: a guide for health professionals. July 2014 Available from http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/

38 Quit SA. Quitline. Available at: http://www.quit.org.au/preparing-to-quit/choosing-best-way-to-quit/quitline

39 Australian Bureau of Statistics. Health Literacy, Australia. Cat.No 4233.0 Canberra: ABS, 2006.

40 Harper E, Lung Foundation Australia, personal communication 2015

41 AIHW Asthma in Australia 2011. Page vii

42 AIHW Asthma in Australia 2011. Page viii

43 Asthma Australia. Asthma in School-aged Children – Available from: http://asthmaaustralia.org.au/ThreeColPB.aspx?pageid=17179869788

44 Blanchard M, Morris J, Birrell E, Stephens-Reicher J, Third A, Burns J. 2014, National Young People and Asthma Survey: issues and opportunities in supporting the health and wellbeing of young people living with asthma. Young and Well CRC, Melbourne.

45 Asthma Australia. Education and Training Framework 2014 – Section 10

46 NAC 2006; Nicholson et al. 2005

47 Department of Health 2011 An outcomes strategy for COPD and Asthma. UK 2011, Department of Health. pp50-51

48 WA Asthma Model of Care p14

49 Am Pharm Assoc 2011, White paper on expanding the role of pharmacists in chronic obstructive pulmonary disease: American Pharmacists Association Foundation, J Am Pharm Assoc ;51:203-211. doi:10.1331/JAPhA.2011.11513

50 Asthma Foundation Australian national conference March 2013 Canberra

51 CHF Chronic Conditions Self Management 1, National Workshop Report: May 2010

52 AIHW How much is spent on asthma. Available from: http://www.aihw.gov.au/asthma/expenditure/

53 AIHW How much is spent on COPD. Available from: http://www.aihw.gov.au/copd/expenditure/

54 Scollo MM and Winstanley MH. Tobacco in Australia: Facts and issues. 4th edn. Melbourne: Cancer Council Victoria; 2012. Available from www.TobaccoInAustralia.org.au

55 Wright D, Twigg M et al Chronic obstructive pulmonary disease case finding by community pharmacists: a potential cost-effective public health intervention International journal of pharmacy practice 2014 doi:10.1111/ijpp.12161

56 Harper E, Lung Foundation Australia, personal communication 2015

57 Lung Foundation Australia. COPD Pharmacy online training - evaluation of pilot. Brisbane 2013

58 National Health Performance Authority. Healthy Communities: frequent GP attenders and their use of health services in 2012-13. Available from: http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Frequent_GP_attenders_Report_March_2015.pdf

59 National Asthma Council Australia. Australian Asthma Handbook. 2014 Available from: http://www.asthmahandbook.org.au

60 Lung Foundation Australia and TSANZ. COPD-X concise guide for primary care. 2014. Available from: http://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-for-primary-care/

61 RACGP. Supporting smoking cessation. A guide for health professionals. 2014. Available from: http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/

62 Australian Medicare Local Alliance. Nurse Clinics in Australian General Practices

63 Lacasse Y, Goldstein R et al. (2006) Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev, CD003793.

64 Ries AL, Bauldoff GS et al. (2007) Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. CHEST, 131, 4S-42S.

65 Griffiths TL, Burr ML et al. (2000) Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet, 355, 362-8.

66 Griffiths TL, Phillips CJ et al. (2001) Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax, 56, 779-84.

67 Puhan MA, Gimeno-Santos E et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD005305. doi: 10.1002/14651858.CD005305.pub3.

http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_Tobacco_Smoking_Rates_Technical_Note_October_2013.pdf

http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_Tobacco_Smoking_Rates_Technical_Note_October_2013.pdf

http://www.tobaccoinaustralia.org.au/7-12-smoking-and-mental-health

http://www.tobaccoinaustralia.org.au/7-12-smoking-and-mental-health

http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/

http://asthmaaustralia.org.au/ThreeColPB.aspx?pageid=17179869788


68 Johnston K, Young M et al. Barriers to, and facilitators for, referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners: a qualitative study. Prim Care Respir J. 2013 Sep;22(3):319-24. doi: 10.4104/pcrj.2013.00062.

69 Johnston K, Young M et al. Frequency of referral to and attendance at a pulmonary rehabilitation programme amongst patients admitted to a tertiary hospital with chronic obstructive pulmonary disease.

Respirology. 2013 Oct;18(7):1089-94. doi: 10.1111/resp.12128.

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