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An Alternative Model of Care
Dr Anna RantaConsultant Neurologist MCDHBAssociate Dean University of Otago
The Waitlist Problem
Dr Anna RantaConsultant Neurologist MCDHBAssociate Dean University of Otago
Overview
Background Improvement Strategies
Nested within Secondary Care Nested at Primary/Secondary Interface
Show casing Non-Contact Specialist Assessments
Lessons Learned and the Way Forward
Why did we bother?
Born out of necessity 2 year wait lists Some patients never seen Non-transparent prioritisation Poor follow up and high DNA rates Poor Team Morale Clinician versus Manager
What did we do?
Consider, understand, and own the problem as a TEAM: Numbers on wait list by priorityNumbers seen each monthNumbers referred each month
Deal with backlog to stop drowning Determine and increase capacity Consider ‘Alternative Models’
Solutions: Secondary Care
Delegate/empower team members:Neuro RN phone/email adviceTechnician education and reportingNurse education and clinicsMDTs
Close relationship with manager to write business cases and manage budgets
Solutions: Primary Care
GP Education and Engagement Teaching (peer review) Guidelines, publications, and audits Clinic letters, emails, phone advice
GP empowered w/ specialist back-up Access to diagnostics (e.g. CT headache) Electronic decision support (e.g.TIA) Limiting follow-up (Non-contact Clinics)
When capacity is reached: Non-contact clinics Aka ‘Virtual’ Clinics’ (FSA and FU) Origins in reluctance to ‘simply turn
patients away’ Not an alternative to face-to-face
assessments, but as an alternative to NO assessments
Tracked, counted, and now funded
What does it entail?
Referrer writes to specialist Patients who are anticipated to
(a) likely wait more than 6 months (b) have simple problems better served
with quick written response (c) needing primarily an investigation
Triaged into “NC-FSA”
Then what?
Prior specialist letters and other relevant documentation/diagnostics reviewed
Some additional diagnostics accessed through secondary care
Management plan created to be implemented in primary care
Formal letter written to GP/referrer w/ option to re-refer
What is the cost?
Face-to-face = 45 min NC-FSA = 15 min Funded at 1/3 regular FSA Now offering NC-FU (not funded) Other similar activities not funded:
RN calls/emails and educationStaff education ‘Curb side’ consults
NC-FSA Audit Data July 2008 – August 2009
Adverse events
3 (1.35%) delays in dx1 (0.45%) detriment
no permanent disability
Referral Details (n=222)
GP Feedback (n=47)
Q1 Did you find the advice helpful in terms of probable diagnosis, management, or simple reassurance?Q2 Did you share the specialist opinion from "non-contact assessments" (virtual clinics) with the patients?Q3 Did you have difficulty when the neurologist said the patient couldn't be seen but advice was provided in writing?Q4 Do you think treating patients via specialist written advice when they cannot be seen within 6 months improves patient care?Q5 If a patient cannot be seen by the neurologist because of lack of resources, would you rather have the referral returned without advice?Q6 Would you rather patients wait longer than 6 months but eventually see the neurologist?
131 surveys sent out, 47 replies received, where % do not add to 100% remainder did not answer question
Overall Benefits
All patients referred receive a specialist opinion
Wait times improved (>2yrs3-6months) Better primary/secondary interface
Empowered yet supported GPs More inter-collegial trust Up-skilled GPs
Care closer to home for patient and often achieved faster
Lessons Learned
Emphasise: Not instead of face-to-face, but instead of no care
Born out of necessity and not a panacea, but a unexpected positives
Specialist the hardest to convince Patient/referrer expectations need to
be managed, but minor hurdle
The Price of Increased Efficiency Traditional model of ‘letting wait list
grow’ alive and well Blame management; need more $ Inequities across services Specialist Training at risk Specialist Existence at risk? Specialist Burn-out?
The ‘Alternative’ Model
Rethinking Specialists role: Shift some specialist resource away
from face-to-face patient contact More emphasis on:
Education, supervision, and support Team approach (within/across sectors) Population Health & Clinical Leadership
Ideally Hospital/DHB/region wide with less focus on our own specialties
Next Steps
Efficiency to be promoted through appropriate rewards/incentives
Funding stream adaptation to properly recognise/fund ‘non-contact’ time
More clinician engagement to ensure safety: work with not against management
Public perception to be further shaped to understand and accept limitations
Strive for good and equitable care across specialties, sectors, and DHBs
Summary
YES, there is a resource problem And NO it is not going to go away BUT in NZ we are well ahead of the game A bit of ‘can do’ attitude goes a long way ‘Can do’ teams with ‘can do’ leaders and
‘can do’ managers even better…. In my mind the goal is to achieve
comprehensive, conscientious, and equitable health care to our entire population
QUESTIONS?