Project Review and Qualitative Process Findings
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Transcript of Project Review and Qualitative Process Findings
Project Review and Qualitative Process
Findings
2007-2010
March 2010
Improving access to health services for vulnerable populations
HRC Access plan 15 practicesapprox 40000 pats3% = 1200 = 100/mth
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STARTstocktake - - - - - -lit reviewapproval Jrecruitsetup visitssoftware dev / testEthics approval RinterventionNV cult comp modulePR friendliness modulecontinue action researchpractice cohort 1 yr before 1 year afterN01 - N12 1 yr before 100 N01 1 yr after
100 N02100 N03
100 N04100 N05
100 N06NV quant analysis stop 600pats with 1yr before / 1 yr afterthrough to N12 N12 …analysisdownload dataNMDS / Phar / labstats etcfinal Report J
Project Review :Summary of trial sites
Tairawhiti DHB Ngati Porou
South Canterbury Aoraki PHO
Northland Mania PHO
Northland Te Tai Tokerau PHO
West Coast DHB
Adaptation of existing rural health nursing service
Continued to code rural health nursing activity. 5 nurses outreaching in relation to several contracts: immunisation; follow up of hospital discharge; CCM and CVD assessment
New project.
1 FTE outreach nurse. PHO employed. Working with 4/28 practices. Outreach contract ended February 2010
Adaptation of existing nurse outreach service
PHO outreach contract renewed and extended to include a CHW. Contract specifies completion of 25-50 home visits per week.
Adaptation of existing practice nurse outreach
Nurse coding issues found in data checks. CBG now supporting back coding for the first quarter in 2010
Adaptation of existing rural health nursing service and new practice based service
Continued to code rural health nursing activity
Practice based service has some capacity issues
Started Dec 2008 Started Nov 2008 – first outreach Jan 2009
Started Dec 2008 Started December 2009
Started April 2009
Description of the trial
2. Maximise value of each contact
BPAC form– Identification of
overdue basic care
3. Cultural awareness training
1. Target outreach
Query and PMS information use
Listed any registered patients with evidence of asthma, diabetes or ischaemic heart disease who have not been seen in the last 6 months.
– Date of last recorded encounter
– All Read codes for these conditions
– Any prescription for Hypoglycaemic medicines Vasodilating nitrates Inhaled steroids or
combination inhalers
Outreach activity to date
Figures to March 2010
DHB Total outreach recipients
Outreach visits
Outreach calls
Outreach other
Northland 687 1105 556 425 South Canterbury
631 357 783
Tairawhiti 437 504 31 306 West Coast 775 491 435 411
Totals 2530 2457 1022 1925
Qualitative Process Evaluation
Discussions focused on the process of delivering the service, more specifically
– Process and operation details
– Identification of events that may have affected implementation or outcomes.
– Next steps/improvements
Interviews completed October 2009 – February 2010
Findings
Stocktake, literature review and formative findings available at www.improving access.co.nz
Targeting outreach and maximising the value of each contact
Few nurses use the PMS effectively Outreach has largely been referral led with
limited checking of eligibility Reasons
1. Nurse attitude towards delivering health care in the home
2. Home visits criteria
3. Employment status
4. Use of IT
5. Capacity issues
Nurses attitude towards offering health care in the home
Exposure to home environments
– Some nurses reluctant to, or unsure about how and when, to approach health issues
– Confronted with socioeconomic problems
Involvement is time consuming Not necessarily qualified to
deal with the issues Transition to health care
– Not smooth– Not always possible
Uncertainty about when to approach health issues
– Embroiled in some situations– Provider, rather than facilitator
of access to, services– Struggle to replace themselves
in the service equation
“ You have to prove yourself when you get in there – Show that you are
going to help. Sort out their benefits so that they can pay for care. You can’t plough in there
asking to take their blood pressure – Not right away!’
Where Home visit criteria exists
Criteria varied across the sites
– Commonly included recall checks– Related to underlying contract requirements– Typically included one or more of the following:
Did not attend secondary care appointment (list provided by the hospital) Recently discharged from hospital (Electronic discharge summary sent to
PMS) Avoidable hospital admission (List provided by the DHB) Overdue screen, immunisation, diabetes follow up (queries run in the PMS) No CVD risk assessment recorded (PHO generated list) Palliative care (referral from a practitioner) CCM programme (List of those eligible from PHO)
Run PMS queries
Generate a list of potential outreach recipients
Assess the list through PMS record check and use of professional’s knowledge about the family
Confirm reason for outreach activity or home visit
No Yes
Adjust PMS record accordingly (e.g. correct coding)
Code outreach in the PMS and complete PMS record results in
Receive referrals
Complete recall. In the event of no response
Complete outreach activity
Referral Based Nursing Outreach
StartRun PMS queries
Generate a list of potential outreach recipients
Assess the list through PMS record check and use of professional’s knowledge
about the family
Confirm reason for outreach activity or home visit
No Yes
Adjust PMS record
accordingly (e.g. correct
coding)
End : Code outreach in the PMS and complete PMS record
StartReceive referrals
Complete recall. In the event of no response
Complete outreach activity
Some referrals will not meet the trial eligibility criteriaFor example: Those seen at the clinic and referred for follow up
Employment status
PHO employed– Protected time to deliver the
service– Work across a number of
practices– Estimate 1FTE can work
across 10-14 GPs or patient population of 20-30,000
Require help to judge eligibility
– More likely to accept all referrals at face value
– Takes time for referees to understand the service
Practice employed– More likely to be prohibited
from outreaching by other duties
– Have the trust of the practice
Know the patients so can judge eligibility
Use of IT
Use PMS to identify
those eligible for outreach
Use best practice reports to
identify / address overdue aspects of
care
Code all outreach activity
In addition to good PMS record keeping. The trial required outreach nurses to:
Use of IT: Findings
Use PMS to identify
Queries abandonedMany referrals
accepted at face value with little
interrogation of PMS
Use best practice reports to
identify / address overdue aspects of
care1 in 3
did not use the
report facility
Code all outreach Activity1 in 5 did not correctly code
PMS record keeping. Some clinical information is incorrectly entered as free text
Some referrals are not recorded in the PMS
Some nurses use external software to provide outreach reports
Reasons: Varied understanding, no adoption of new practice ,preferences for more traditional practice/referrals based service
Capacity
Large variation in number of calls, visits and other activities accomplished by 1 FTE per week
– Predominantly associated with underlying contract and employment arrangements
1. “I complete 4-5 visits in two and a half days” [PHO employed working across 2 practices with limited management support and no activity requirements specified in the service contract]
2. “We have done about 30 visits in the last couple of months – To be honest I have been busy with other things. We are one practice nurse down and we are just trying to fit this in when we can.”
[Practice nurses with no activity requirements specified in the service contract]
1. “About 4-5 visits a day –most weeks it would be 20-30. Our PHO contract requires that number of visits – I have to follow up all DNAs and all those who don’t have a CVD risk measurement and now immunisations and screening.” [Practice employed, number of outreach visits required specified in the service contract ]
Service delivery
Resource use
Reengagement with health services often depends on
– Actions of other services– Nurses address of
socioeconomic issues Struggle to navigate and
secure help Exposes gaps in and
problems gaining access to other services
Who should fund?
Can the health budget sustain use of its resource to address socioeconomic problems?
Local service directories
Did not exist in some areas
Nurses assimilated their own information– Time taken and process used variable– End result was sometimes an informal directory
that could not be used by others
Other events affecting the services
External Environment
H1N1 influenzaAdverse weather
conditions
Recession and associated increase
in unemploymentCapacity issue
Preventing travel in some areasResulting in increased demand to address socioecon problems
Feedback on cultural awareness training
Content of the three sessions did not :
Take into account existing cultural accreditation, knowledge or practice
Meet attendees’ expectations Advance existing knowledge
or practice
Delivery of the 3 sessions was criticized on the basis of:
Facilitator skill and experience level
Expectation that the course would be delivered by a recognized cultural expert
Time involved for practices in relation to outcome from session attendance
Delivery style not conducive with group interaction, and perception that it could be effectively delivered by distance learning
Lessons for the future
Issue Future considerations
Wide variation Who receives outreachContact rates
Service contracts should make explicit:
1. Outreach criteria that details who is eligible and the criteria for a home visit
2. The expected contact rates by type (call/visits/other) per FTE per week
Large amount of socioeconomic work
The sectors involved should explore possible multi-sectorial models of funding and service delivery
Risk of inappropriate referrals
1. The outreach criteria should be made available, and explained, to each referrer
2. Referral acceptance should be subject to : Further investigation using the PMS records and practitioner knowledge to
identify and record the fit with the agreed outreach criteria Acceptance by a senior manager who is responsible for the
implementation of the service in accordance with the contract specifications.
Lessons for the future
Issue Future considerations
Value of nurse involvement and the need for some standards in practice
The nursing sector should advise on post graduate education for outreach nurses. At a minimum nurses should receive training on:
1. The outreach role
2. Cost of outreach services
3. Engaging harder to reach audiences
4. Implementation of outreach criteria
5. Working with a defined scope of outreach practice
6. How to investigate and triage outreach referrals
7. Use of the PMS to record activities, code work, and identify and address overdue aspects of care
8. How to approach health issues in the home environment and transition between socioeconomic issues and health problems
9. Effective use of service directories
Employment arrangements for outreach nurses
PHO employed nurses should be afforded more time to engage practice staff in the outreach work
Practice based nurses require protected time to complete outreach activities.
Lessons for the future
Issue Future considerations
Room to advance outreach cultural awareness training
The course should be delivered by an experienced group facilitator who is also a recognized cultural expert.
The content should be advanced to:
1. Include more expert advice on the impact of cultural beliefs on health states and perceptions and use of general practice services.
2. Provide education on face to face and telephone engagement of people and teachings about Maori structure and its importance.
3. Invite practices to provide insight into their existing knowledge levels and practice friendliness strategies.
4. Tailor the offering to build on existing problems, strategies, knowledge and practice
5. Ensure course attendees receive expected learning outcomes which highlight how the course will help to build on existing strategies and knowledge.