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
Northern Respiratory Partnership Final Project Report – May 2013 to 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
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
99
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)
Lung Foundation Australia
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.
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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
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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.
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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.
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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.
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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
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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.
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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.
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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
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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.
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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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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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
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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%
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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%
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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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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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
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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
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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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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-
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
45
IMPLEMENTATION OF KEY ACTIVITIES
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.”
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
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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.
PROPOSED WAY FORWARD
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.
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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.
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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
PROPOSED WAY FORWARD
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
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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)
IMPLEMENTATION OF KEY ACTIVITIES
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.
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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.
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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
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PROPOSED WAY FORWARD
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.
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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
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IMPLEMENTATION OF KEY ACTIVITIES
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
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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
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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.
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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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65
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
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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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72
PROPOSED WAY FORWARD
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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PROPOSED WAY FORWARD
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.
PROPOSED WAY FORWARD
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.
PROPOSED WAY FORWARD
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
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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
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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.
PROPOSED WAY FORWARD
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
IMPLEMENTATION OF KEY ACTIVITIES
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.
PROPOSED WAY FORWARD
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
Lung Foundation Australia
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.
PROPOSED WAY FORWARD
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
PROPOSED WAY FORWARD
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.
PROPOSED WAY FORWARD
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.
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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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Appendix 1 Northern Respiratory Partnership partner organisations and expected
contribution
NRP partner organisations Expected contribution
Northern Adelaide Medicare Local
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
Lung Foundation Australia
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Appendix 2 NRP project plan March 2014 (revised from April 2013)
Northern Adelaide Medicare Local
Northern Respiratory Partnership
Project Plan
March 2013
(revised April 2014)
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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)
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 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
Northern Respiratory Partnership Final Project Report – May 2013 to May 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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Appendix 3 Information sheet to general practices on NRP opportunities
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Appendix 4 Asthma Assist referral form
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Issue What strategies have been implemented?
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
Maximise use of hospital
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Issue What strategies have been implemented?
Maximise use of hospital
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
Appendix 7 Maps showing COPD prevalence and pulmonary rehabilitation services
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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?
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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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/
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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
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
Northern Respiratory Partnership Final Project Report – May 2013 to May 2015
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.
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