Project Review and Qualitative Process

Findings

2007-2010

March 2010

Improving access to health services for vulnerable populations

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STARTstocktake - - - - - -lit reviewapproval Jrecruitsetup visitssoftware dev / testEthics approval RinterventionNV cult comp modulePR friendliness modulecontinue action researchpractice cohort 1 yr before 1 year afterN01 - N12 1 yr before 100 N01 1 yr after

100 N02100 N03

100 N04100 N05

100 N06NV quant analysis stop 600pats with 1yr before / 1 yr afterthrough to N12 N12 …analysisdownload dataNMDS / Phar / labstats etcfinal Report J

Project Review :Summary of trial sites

Tairawhiti DHB Ngati Porou

South Canterbury Aoraki PHO

Northland Mania PHO

Northland Te Tai Tokerau PHO

West Coast DHB

Adaptation of existing rural health nursing service

Continued to code rural health nursing activity. 5 nurses outreaching in relation to several contracts: immunisation; follow up of hospital discharge; CCM and CVD assessment

New project.

1 FTE outreach nurse. PHO employed. Working with 4/28 practices. Outreach contract ended February 2010

Adaptation of existing nurse outreach service

PHO outreach contract renewed and extended to include a CHW. Contract specifies completion of 25-50 home visits per week.

Adaptation of existing practice nurse outreach

Nurse coding issues found in data checks. CBG now supporting back coding for the first quarter in 2010

Adaptation of existing rural health nursing service and new practice based service

Continued to code rural health nursing activity

Practice based service has some capacity issues

Started Dec 2008 Started Nov 2008 – first outreach Jan 2009

Started Dec 2008 Started December 2009

Started April 2009

Description of the trial

2. Maximise value of each contact

BPAC form– Identification of

overdue basic care

3. Cultural awareness training

1. Target outreach

Query and PMS information use

Listed any registered patients with evidence of asthma, diabetes or ischaemic heart disease who have not been seen in the last 6 months.

– Date of last recorded encounter

– All Read codes for these conditions

– Any prescription for Hypoglycaemic medicines Vasodilating nitrates Inhaled steroids or

combination inhalers

Outreach activity to date

Figures to March 2010

DHB Total outreach recipients

Outreach visits

Outreach calls

Outreach other

Northland 687 1105 556 425 South Canterbury

631 357 783

Tairawhiti 437 504 31 306 West Coast 775 491 435 411

Totals 2530 2457 1022 1925

Qualitative Process Evaluation

Discussions focused on the process of delivering the service, more specifically

– Process and operation details

– Identification of events that may have affected implementation or outcomes.

– Next steps/improvements

Interviews completed October 2009 – February 2010

Findings

Stocktake, literature review and formative findings available at www.improving access.co.nz

Targeting outreach and maximising the value of each contact

Few nurses use the PMS effectively Outreach has largely been referral led with

limited checking of eligibility Reasons

1. Nurse attitude towards delivering health care in the home

2. Home visits criteria

3. Employment status

4. Use of IT

5. Capacity issues

Nurses attitude towards offering health care in the home

Exposure to home environments

– Some nurses reluctant to, or unsure about how and when, to approach health issues

– Confronted with socioeconomic problems

Involvement is time consuming Not necessarily qualified to

deal with the issues Transition to health care

– Not smooth– Not always possible

Uncertainty about when to approach health issues

– Embroiled in some situations– Provider, rather than facilitator

of access to, services– Struggle to replace themselves

in the service equation

“ You have to prove yourself when you get in there – Show that you are

going to help. Sort out their benefits so that they can pay for care. You can’t plough in there

asking to take their blood pressure – Not right away!’

Where Home visit criteria exists

Criteria varied across the sites

– Commonly included recall checks– Related to underlying contract requirements– Typically included one or more of the following:

Did not attend secondary care appointment (list provided by the hospital) Recently discharged from hospital (Electronic discharge summary sent to

PMS) Avoidable hospital admission (List provided by the DHB) Overdue screen, immunisation, diabetes follow up (queries run in the PMS) No CVD risk assessment recorded (PHO generated list) Palliative care (referral from a practitioner) CCM programme (List of those eligible from PHO)

Run PMS queries

Generate a list of potential outreach recipients

Assess the list through PMS record check and use of professional’s knowledge about the family

Confirm reason for outreach activity or home visit

No Yes

Adjust PMS record accordingly (e.g. correct coding)

Code outreach in the PMS and complete PMS record results in

Receive referrals

Complete recall. In the event of no response

Complete outreach activity

Referral Based Nursing Outreach

StartRun PMS queries

Generate a list of potential outreach recipients

Assess the list through PMS record check and use of professional’s knowledge

about the family

Confirm reason for outreach activity or home visit

No Yes

Adjust PMS record

accordingly (e.g. correct

coding)

End : Code outreach in the PMS and complete PMS record

StartReceive referrals

Complete recall. In the event of no response

Complete outreach activity

Some referrals will not meet the trial eligibility criteriaFor example: Those seen at the clinic and referred for follow up

Employment status

PHO employed– Protected time to deliver the

service– Work across a number of

practices– Estimate 1FTE can work

across 10-14 GPs or patient population of 20-30,000

Require help to judge eligibility

– More likely to accept all referrals at face value

– Takes time for referees to understand the service

Practice employed– More likely to be prohibited

from outreaching by other duties

– Have the trust of the practice

Know the patients so can judge eligibility

Use of IT

Use PMS to identify

those eligible for outreach

Use best practice reports to

identify / address overdue aspects of

care

Code all outreach activity

In addition to good PMS record keeping. The trial required outreach nurses to:

Use of IT: Findings

Use PMS to identify

Queries abandonedMany referrals

accepted at face value with little

interrogation of PMS

Use best practice reports to

identify / address overdue aspects of

care1 in 3

did not use the

report facility

Code all outreach Activity1 in 5 did not correctly code

PMS record keeping. Some clinical information is incorrectly entered as free text

Some referrals are not recorded in the PMS

Some nurses use external software to provide outreach reports

Reasons: Varied understanding, no adoption of new practice ,preferences for more traditional practice/referrals based service

Capacity

Large variation in number of calls, visits and other activities accomplished by 1 FTE per week

– Predominantly associated with underlying contract and employment arrangements

1. “I complete 4-5 visits in two and a half days” [PHO employed working across 2 practices with limited management support and no activity requirements specified in the service contract]

2. “We have done about 30 visits in the last couple of months – To be honest I have been busy with other things. We are one practice nurse down and we are just trying to fit this in when we can.”

[Practice nurses with no activity requirements specified in the service contract]

1. “About 4-5 visits a day –most weeks it would be 20-30. Our PHO contract requires that number of visits – I have to follow up all DNAs and all those who don’t have a CVD risk measurement and now immunisations and screening.” [Practice employed, number of outreach visits required specified in the service contract ]

Service delivery

Resource use

Reengagement with health services often depends on

– Actions of other services– Nurses address of

socioeconomic issues Struggle to navigate and

secure help Exposes gaps in and

problems gaining access to other services

Who should fund?

Can the health budget sustain use of its resource to address socioeconomic problems?

Local service directories

Did not exist in some areas

Nurses assimilated their own information– Time taken and process used variable– End result was sometimes an informal directory

that could not be used by others

Other events affecting the services

External Environment

H1N1 influenzaAdverse weather

conditions

Recession and associated increase

in unemploymentCapacity issue

Preventing travel in some areasResulting in increased demand to address socioecon problems

Feedback on cultural awareness training

Content of the three sessions did not :

Take into account existing cultural accreditation, knowledge or practice

Meet attendees’ expectations Advance existing knowledge

or practice

Delivery of the 3 sessions was criticized on the basis of:

Facilitator skill and experience level

Expectation that the course would be delivered by a recognized cultural expert

Time involved for practices in relation to outcome from session attendance

Delivery style not conducive with group interaction, and perception that it could be effectively delivered by distance learning

Lessons for the future

Issue Future considerations

Wide variation Who receives outreachContact rates

Service contracts should make explicit:

1. Outreach criteria that details who is eligible and the criteria for a home visit

2. The expected contact rates by type (call/visits/other) per FTE per week

Large amount of socioeconomic work

The sectors involved should explore possible multi-sectorial models of funding and service delivery

Risk of inappropriate referrals

1. The outreach criteria should be made available, and explained, to each referrer

2. Referral acceptance should be subject to : Further investigation using the PMS records and practitioner knowledge to

identify and record the fit with the agreed outreach criteria Acceptance by a senior manager who is responsible for the

implementation of the service in accordance with the contract specifications.

Lessons for the future

Issue Future considerations

Value of nurse involvement and the need for some standards in practice

The nursing sector should advise on post graduate education for outreach nurses. At a minimum nurses should receive training on:

1. The outreach role

2. Cost of outreach services

3. Engaging harder to reach audiences

4. Implementation of outreach criteria

5. Working with a defined scope of outreach practice

6. How to investigate and triage outreach referrals

7. Use of the PMS to record activities, code work, and identify and address overdue aspects of care

8. How to approach health issues in the home environment and transition between socioeconomic issues and health problems

9. Effective use of service directories

Employment arrangements for outreach nurses

PHO employed nurses should be afforded more time to engage practice staff in the outreach work

Practice based nurses require protected time to complete outreach activities.

Lessons for the future

Issue Future considerations

Room to advance outreach cultural awareness training

The course should be delivered by an experienced group facilitator who is also a recognized cultural expert.

The content should be advanced to:

1. Include more expert advice on the impact of cultural beliefs on health states and perceptions and use of general practice services.

2. Provide education on face to face and telephone engagement of people and teachings about Maori structure and its importance.

3. Invite practices to provide insight into their existing knowledge levels and practice friendliness strategies.

4. Tailor the offering to build on existing problems, strategies, knowledge and practice

5. Ensure course attendees receive expected learning outcomes which highlight how the course will help to build on existing strategies and knowledge.