Local Health District Clinical Services · PDF fileRenal Clinical Services Plan 2013 ‐2017 ... 4.1.3 National Primary Health Care Strategic ... A goal of the Murrumbidgee Local Health

Murrumbidgee Local Health District Renal Clinical Services Plan

2013‐2017

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Murrumbidgee Local Health District Renal Clinical Services Plan 2013‐2017 Version 2.0

Table of Contents Table of Contents ......................................................................................................... 33 List of tables ................................................................................................................. 55 List of figures ................................................................................................................ 55 Message from the Chief Executive .............................................................................. 88 1. Executive Summary .............................................................................................. 99 2. Introduction and Background .......................................................................... 1111 2.1 Overview to Plan Development .................................................................... 1111 2.2 The Planning process .................................................................................... 1111 2.3 Scope of the Renal Clinical Services Plan ...................................................... 1111 3. MLHD Renal Services – Overview .................................................................... 1212 3.1 MLHD Current Service Provision ................................................................... 1212 3.1.1 Health Promotion ...................................................................................... 1313 3.1.2 Chronic Disease Management Program.................................................... 1313 3.1.3 Chronic Care for Aboriginal People ........................................................... 1414 3.1.4 Diabetes Specialists ................................................................................... 1414 3.1.5 Kidney Health Check .................................................................................. 1515 3.1.6 Diagnosis, Investigation and Management ............................................... 1515 3.1.7 Pre‐ Dialysis Education .............................................................................. 1515 3.1.8 Haemodialysis‐ Satellite / In‐ Centre ......................................................... 1515 3.1.9 Home Dialysis ............................................................................................ 1616 3.1.10 Multidisciplinary team............................................................................... 1717 3.1.11 Self‐care Haemodialysis ............................................................................ 1717 3.1.12 Renal Supportive Services ......................................................................... 1717 3.1.13 Renal Transplantation ............................................................................... 1717 4. Policy Context .................................................................................................. 1818 4.1 National Policy Context ................................................................................. 1818 4.1.1 Preventative Health ................................................................................... 1818 4.1.2 Aboriginal Health ....................................................................................... 1818 4.1.3 National Primary Health Care Strategic Framework ................................. 1818 4.2 NSW Policy Context....................................................................................... 1818 4.2.1 Population Health Priorities for NSW: 2012‐2017 .................................... 1919 4.2.2 Chronic Care .............................................................................................. 1919 4.2.3 Chronic Care for Aboriginal People ........................................................... 1919 4.2.4 Kidney Health Check: Promoting the Early Detection and Management of Chronic Kidney Disease (PD2010_023) .................................................................... 1919 4.2.5 NSW Renal Dialysis Service Plan 2011 ...................................................... 1919 4.2.6 Palliative Care Strategic Framework 2010‐2013 ....................................... 2020 4.3 Murrumbidgee Local Health District Strategic Directions ............................ 2020 5. The people of the Murrumbidgee Local Health District .................................. 2121 6. Prevalence and Demand .................................................................................. 2323 6.1 Chronic Kidney Disease ................................................................................. 2323 6.2 Diabetes ........................................................................................................ 2424 6.3 Hypertension ................................................................................................. 2525 6.4 Aboriginal Population ................................................................................... 2525

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List of tables TABLE 1: MLHD RENAL CLINICAL SERVICE PLAN EXCLUSIONS

TABLE 2: MLHD DIABETES SUPPORT STAFF

TABLE 3: DIABETES RELATED BURDEN OF DISEASE IN MLHD

TABLE 4: CHRONIC KIDNEY DISEASE SERVICE (PRE DIALYSIS CARE) WITH GFR <20

TABLE 5: MLHD INPATIENT DATA 2010‐12

TABLE 6: ADMITTED PATIENTS WITH CHRONIC KIDNEY DISEASE RECEIVING TREATMENT AT WAGGA

WAGGA BASE HOSPITAL

TABLE 7: ADMITTED PATIENTS WITH CHRONIC KIDNEY DISEASE RECEIVING TREATMENT AT GRIFFITH

BASE HOSPITAL

TABLE 8: HOME DIALYSIS SERVICES IN MLHD

TABLE 9: RENAL DIALYSIS SELF‐CARE FACILITIES IN MLHD

TABLE 10: MLHD SATELLITE / IN‐CENTRE HAEMODIALYSIS SERVICES

TABLE 11: PROJECTED DEMAND CHANGE FOR DIALYSIS BY PLANNING CLUSTER

TABLE 12: PROJECTED INCREASE IN WAGGA WAGGA PLANNING CLUSTER

List of figures FIGURE 1: CURRENT RENAL SERVICES PROVIDED ACROSS MLHD

FIGURE 2: HEALTH PROMOTION CONTINUUM

FIGURE 3: MLHD STRATEGIC PLAN 2012‐2015 – ESSENTIAL ELEMENTS

FIGURE 4: OVERALL POPULATION PROJECTIONS FOR THE MLHD 2011 TO 2031

FIGURE 5: AGE GROUP POPULATION PROJECTIONS FOR THE MLHD 2011 TO 2031

FIGURE 6: STAGES OF KIDNEY DISEASE AS MEASURED BY THE APPROXIMATE KIDNEY FUNCTION LOST

FIGURE 7: DIALYSIS INDEICENCE RATES (PER MILLION POPULATION) FOR INDIGENOUS AND NON INDIGENOUS POPULATIONS IN AUSTRALIA FIGURE 8: CURRENT DIALYSIS THERAPY UTILISATIO IN THE MLHD VERSUS AUSTRALIA

FIGURE 9: FUTURE RENAL SERVICES PROPOSED IN MLHD AS FUNDING ALLOWS

FIGURE 10: MEDICARE LOCAL BOUNDARIES IN M

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Nephrologist: A highly trained doctor who specialises in looking after people with kidney failure.

Nurse Practitioner:

A Registered Nurse able to work autonomously and collaboratively in an advanced clinical role, this is. The title Nurse Practitioner is that bestowed upon an individual who has been able to demonstrate to the Nursing and Midwifery Board they meet the requirements of this registration classification and are therefore authorised. A Transitional Nurse Practitioner is a Registered Nurse who is undertaking formal preparation to become a Nurse Practitioner, generally works at a CNC (Level 2) while working towards the Nurse Practitioner qualification.

Peritoneal Dialysis:

Artificial method for removing toxins from the body by infusing a solution into the peritoneum via a catheter, which absorbs the toxins and then drains away, performed either by the patient or using an automatic machine.

Primary Health Care: Describes the management of the population by General Practitioners, Aboriginal Medical Service, Dieticians, Physiotherapists and health screening programs.

Satellite/In‐Centre Dialysis:

The dialysis is provided in a facility close to the parent hospital where renal nurses perform the dialysis treatment as patients are too unwell or frail to assist in their own care, or home situation is unsuitable with no support from family.

Self‐Care Dialysis:

The dialysis machines are provided in a location away from the patient’s home but close to the health facility in their town. Clinically suitable patients perform their own dialysis following training, with ongoing support from their governing renal unit, no nurses are present.

Telehealth:

Telehealth is considered to include in its scope ‘the transmission of images, voice and data between two or more health units via telecommunication channels to provide clinical advice, consultation, education and training services.’ [NSW Health, 2001] This allows for consultation with doctors, nurses and patients who are not in the same area decreasing the need to travel for patients and staff.

Tertiary Referral Hospitals:

These are large teaching hospitals based in the metropolitan areas with extensive facilities and expertise that will accept patients from Rural and Remote areas whose care has become too complicated and difficult to manage for local hospitals.

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1. Executive Summary A goal of the Murrumbidgee Local Health District (MLHD) is to reduce the burden of Chronic Kidney Disease in our community. To achieve this, the MLHD will work collaboratively to provide a range of renal services across the care continuum. Services will have a population health approach and will be:

Patient centred;

Safe and high quality.

Accessible;

Multidisciplinary and collaborative Chronic Kidney Disease (CKD) is a chronic condition impacted by lifestyle and behaviour Across the population, this means promoting good health and implementing strategies to maintain this. Health promotion strategies delivered by a range of health agencies, must focus on good kidney health by maintaining a healthy weight and blood pressure and being physically active. For those at risk of kidney disease, reducing the burden of chronic kidney disease means working with key partner agencies to detect Kidney Disease earlier and work with patients to slow the disease. In the life of this plan, there will be a greater emphasis on screening the at‐risk population through broader implementation of the Kidney Health Check screening program. Health promotion strategies will also apply to this group, and the management of diabetes and hypertension will be important. Strategies such as the Chronic Disease Management Program and Chronic Care for Aboriginal People will play an important role in reducing the occurrence of Chronic Kidney Disease. For those living with Chronic Kidney Disease our goal means ensuring access to high quality, accessible and timely care, based on the best models of service delivery. We have a greater reliance on in centre/ Satellite dialysis services than the Australian average, and the demand for such services are expected to increase due to current under diagnosis, our ageing population and rise in other complex chronic diseases. The MLHD will therefore look to develop models of care for renal services that deliver services closer to home and increase opportunities for home‐based treatments to reduce the significant travel burden on patients and families. We will also focus on securing more specialised nephrology services for the District, and investigate how a range of dialysis service models can be delivered in Key strategic locations across the District Partnerships are also a key tenant of this plan. The MLHD will continue to work to strengthen current partnerships and develop new ones with agencies who play an important role in kidney health promotion, early detection and treatment. Medicare Locals, Aboriginal Medical Services and General Medical Practices are the important stakeholders identified in this plan. The MLHD will work to provide better services for Aboriginal people. Aboriginal people are at a greater risk of chronic kidney disease than non‐Aboriginal people so we will work with Aboriginal Medical Services, to increase screening of Aboriginal people to detect kidney disease earlier. The MLHD will provide more culturally appropriate and safe services through training and education.

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Murrumbidgee Local Health District Renal Clinical Services Plan 2013‐2017

2. Introduction and Background

2.1 Overview to Plan Development The development of the MLHD Renal Clinical Services Plan was identified in 2012 as a Priority Action of the LHD Strategic Plan (MLHD, 2012). The Plan identifies the most important issues the LHD has to address in order to provide relevant and sustainable renal services for the Murrumbidgee communities into the future.

2.2 The Planning process The MLHD Chief Executive established a Renal Clinical Services Plan Steering Committee in 2012. The Steering Committee comprised of clinicians, senior managers and consumers, and was responsible for overseeing the development of the MLHD Renal Clinical Services Plan. (Appendix 1: Steering Committee Membership and Terms of Reference) A consultation program was undertaken from June 2012 to October 2013 with staff, clinicians, external agencies and local communities. In addition to the consultation program, the Steering Committee undertook a data mapping exercise, which included reviewing population data and a spatial distribution exercise. A summary of data used to inform the plan are provided in Appendices 2 and 3.

2.3 Scope of the Renal Clinical Services Plan The scope for the Renal Clinical Services Plan is the ‘education, care and management of adults with any form of kidney disease’, with a primary focus on:

Health promotion and prevention;

Primary health care;

Screening and early intervention ;

Disease management and supportive therapy.

Adults with any form of kidney disease include people who:

Have diagnosed kidney disease;

Have known risk factors and may have undiagnosed kidney disease;

Are at any of stage of renal failure. Whilst the Plan covers a spectrum of renal services, the plan does not include renal services for children aged 16 years and younger; or transplantation. A summary of exclusions is provided in Table 1:

TABLE 1: MLHD RENAL CLINICAL SERVICE PLAN EXCLUSIONS

Exclusion Rationale

Renal services for Children aged 16 years and younger

All children’s renal services are delivered from the Sydney Children’s Hospitals Network (Randwick and Westmead)

Transplantation All transplantation services are delivered by Tertiary Referral Hospitals

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3.1.1 Health Promotion

The MLHD Health Promotion Unit operates at a population level to create supportive environments and develop healthy public policy that enables communities to increase control over and improve their health. Health professionals within MLHD also work with individuals and groups to increase awareness, improve knowledge and develop skills that create health literacy. The continuum of health promotion approaches is represented at Figure 2:

FIGURE 2: HEALTH PROMOTION CONTINUUM

Individual Population

Downstream Midsteam Upstream

Individual targeted strategies Group based local lifestyle programs. Determinants of health

Screening health education community action settings and supportive environments

Clinicians HP specialists

Examples of “downstream” and “midstream” targeted strategies include:

Screening for early detection of renal disease

Individual and group based health education e.g. smoking cessation, food skills, life skills, awareness raising such as Kidney Awareness Week, National Heart Foundation Walking groups; and

Access to support services e.g. referral to Quit line, Get Healthy Coaching Service,

Enabling local community action e.g. for improved access to renal services for those most in need.

Examples of “upstream” actions to create supportive environments and reduce inequity include:

Tobacco policy

Affordable and safe food supply

Social inclusion strategies

Large scale social marketing of positive messages

Efficient and accessible transport

Healthy built environments

3.1.2 Chronic Disease Management Program

The Chronic Disease Management Program offers clients with chronic and complex needs coordinated care between General Practice and the LHD. This coordination includes other providers who may be involved with the client and their carer, such as private allied health providers. The focus of the program is client centred with the client and carer actively involved and supported in decision making and in the monitoring and management of their health and health goals. Eligibility for the program requires at least one listed chronic condition with complex needs which places the client at risk of hospitalisation or a loss of functional independence. Eligible

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3.1.5 Kidney Health Check A Kidney Health Check provides opportunistic screening, to identify inpatients at risk of Chronic Kidney Disease. The Check is mandated by NSW Health Policy Directive Kidney Health Check: Promoting the Early Detection and Management of Chronic Kidney Disease (PD2010_023), and consists of three steps:

1. Identify – Identification of High Risk Patients 2. Check – Kidney Health Check 3. Refer – Follow up

Hospitals are to implement the Kidney Health Check in high‐risk inpatient groups such as cardiology, cardiovascular, general medicine, endocrine, stroke, rehabilitation, geriatric medicine, and include patients undergoing cardiac and vascular surgery. Over time, screening will be expanded to high‐risk outpatient clinics and Emergency Departments.

3.1.6 Diagnosis, Investigation and Management MLHD Renal Services provide comprehensive secondary services in relation to the diagnosis, investigation and management of adults with renal disease. Specific services provided are represented in Figure 1. The Royal Price Alfred Hospital (RPA), The Canberra Hospital, Austin Health (The Austin) and The Royal Melbourne Hospital (Royal Melbourne) are accessed for the majority of acute referrals. These tertiary hospitals also provide haemodialysis and peritoneal dialysis training.

3.1.7 Pre‐ Dialysis Education The role of patient education in preparing patients for End Stage Renal Failure treatment is paramount. These patients have many life changes to consider and are expected to learn new information, skills and strategies for immediate self‐care; and long term changes in lifestyle. Often this is within a short period of time and under highly stressful conditions. The aim of a patient education program is to provide a planned pathway which enables patients to understand their disease process, available treatment options and resulting lifestyle changes. Preparation is an essential process for facilitating patients' physical and psychosocial adaptation to the progression of End Stage Renal Disease and its treatments. Education, support and consultation is central to promoting independence with home dialysis, alleviating anxiety associated with impending treatment, and providing information for informed decision‐making.

3.1.8 Haemodialysis‐ Satellite / In‐ Centre

Haemodialysis is one form of treatment for renal failure where the functions of the kidneys are replaced by a machine. Treatment requires the patient to undergo dialysis for 3‐6 hours, three days per week and may be undertaken in a patient's home, self‐care unit, satellite dialysis centre or hospital. Patients are assessed to determine the most appropriate location for treatment. Dialysis is provided in a facility close to the parent hospital where renal nurses perform the dialysis treatment when patients are too unwell or frail to assist in their own care, or the home situation is unsuitable with no personal support available.

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Have access to town water: Patients who only have access to tank/ rain water are ineligible for home haemodialysis due to the high rate at which dialysis uses water and;

Have access to mains electricity: i.e. ‐ power cannot be via a generator.

3.1.10 Multidisciplinary team

The Renal Dietician is a 1.0 FTE based in Wagga, covering both Wagga and Griffith. This position provides specialised dietary advice and counselling to patients whose estimated Glomerular Filtration Rate (eGFR) is 30 or below (i.e. Stage 4 or 5). This includes those receiving in centre dialysis. Patients who have an eGFR of between 45 and 30 (i.e. Stage 3a and 3b) are referred to a generalist community dieticians. The Renal Social Worker is a 0.6FTE position based in Wagga, covering Wagga and Griffith. This position provides social/ emotional support to renal patients and their carers, assistance with transport and referral to other services as needed.

3.1.11 Self‐care Haemodialysis

The Self‐care Units adopt a model of Self‐care Haemodialysis in a Hospital Setting, and are suitable for patients who are identified by their renal physician as clinically suitable and able to manage their own treatments. This service allows patients to remain in their home town and offers flexibility and improvement to their lifestyle. This model aims to provide a place for patients to dialyse where their home environment is not suitable or not preferable. The patient can access this facility 24 hours per day to independently undertake their own Haemodialysis once trained through a home training unit. Facilities are usually separate to the Hospital, though on hospital grounds and on‐site hospital staff are not part of this model. MLHD has opened three self‐care units at West Wyalong, Young and Tumut. The Medical Governance of these units is overseen by The Canberra Hospital. An outreach nurse is responsible for the support of these patients in the same capacity as other patients on home therapies.

3.1.12 Renal Supportive Services Supportive treatment in kidney care refers to patients in End Stage Kidney Disease who have chosen or are not suitable for renal replacement therapies. Patients are actively treated with medication for relief of symptoms. At the final stage of this management plan patients may need palliative care services.

3.1.13 Renal Transplantation Transplantation of kidneys is a small but important component part of Renal Services delivery. All transplantations take place in Tertiary Referral Hospitals, outside of the District. MLHD works closely with these Facilities in pre and post transplantation phases of care.

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4.2.1 Population Health Priorities for NSW: 2012‐2017

Population Health Priorities for NSW: 2012‐2017, provides the overarching strategic priorities, key actions and measures of success for population health activity undertaken by NSW Health Agencies. The NSW population health priorities are:

Close the gap in Aboriginal life expectancy

Promote healthy populations

Protect the population from threats to health

Build and maintain healthy environments A Population Health Plan is being developed for the MLHD, concurrently to the Renal Clinical Services Plan, and will be largely influenced by these priorities.

4.2.2 Chronic Care

The NSW Chronic Disease Management Program (Connecting Care in the Community) is focused on five major chronic diseases of interest that are recognised as having a major impact on the burden of disease in NSW. Furthermore, these conditions have been demonstrated to have improved outcomes through Chronic Disease Management approaches. MLHD has developed a Framework for the Program, based on local needs and service configuration, as described above (Section 3.1)

4.2.3 Chronic Care for Aboriginal People

Aboriginal health workers are an integral member of chronic care teams. Engagement of the Aboriginal community and the Aboriginal Medical Services (AMS) is vital and at a local level, the development of trusting relationships with all related parties must be a priority. The Chronic Care for Aboriginal People: Model of Care provides a strategic Program under which many of the MLHD programs relate (NSW Department of Health, 2010).

4.2.4 Kidney Health Check: Promoting the Early Detection and Management of Chronic Kidney Disease (PD2010_023)

The Kidney Health Check policy directive outlines an approach to the early detection and management of chronic kidney disease to prevent progression to end stage kidney disease. It involves opportunistic screening using the Kidney Health Check in order to identify risk of chronic kidney disease, and will target high‐risk individuals in hospital settings.

4.2.5 NSW Renal Dialysis Service Plan 2011

The NSW Renal Dialysis Service Plan to 2011 provides guidance to LHDs in the organisation of renal care. The Plan provides benchmarks for the distribution of different treatment modalities; and describes state‐wide strategies relating to purchasing, data management, workforce development and transportation. The plan also emphasises the important of home dialysis and promotes a 50:50 ratio of home (both home haemodialysis and peritoneal dialysis) to centre‐based dialysis services. Importantly, the plan outlines ten principles for the management of people with Chronic Renal Disease. An overview of the principles in this document is provided in Appendix 1.

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5. The people of the Murrumbidgee Local Health District

5.1 A note regarding population figures There are some differences in the total population numbers of MLHD used in this plan. This is due to the use of both 2006 and 2010 Census data; the inclusion / exclusion of Lake Cargelligo across data sets; and the different sources of data the plan must draw on. The population projections used in this document are those which are provided and mandated by the NSW Ministry of Health for planning purposes. Although raw population numbers may differ, the overall trends and proportions remain the same. Albury Local Government Area is included in this plan and although Albury Base Hospital is now administered by Albury Wodonga Health; these residents continue to receive a variety of health services from MLHD.

5.2 Population overview The MLHD, as at 30 June 2011, had an estimated resident population of 286,176. Between the last two Census’, the population has increased at a rate of approximately one per cent; smaller than the state wide growth of 5.6 per cent. See Appendix 3 for additional population data. NSW Ministry of Health projections for the show a steady but small overall growth through the decades in the overall population. This is shown in Figure 4:

FIGURE 4: OVERALL POPULATION PROJECTIONS FOR THE MLHD 2011 TO 2031

Source: NSW Ministry of Health, 2009

While the overall population is expected to increase, this growth is not distributed equally across the region. Growth in the MLHD population is focused in the LGAs of Albury, Corowa, Griffith, Murray, Wagga Wagga and Young with lower patterns of growth anticipated in the areas of Coolamon, Leeton and other Murrumbidgee local government areas. Many of the remaining areas within the District are expected to have stable or declining populations.

5.3 Age profile In 2011, there were 50,396 people aged 65 years and older who in resided in the MLHD. This figure is expected to grow steadily over the coming decades, with the number expected to reach a total of 86,254 in 2031 (State‐wide Service Development, 2010). The growth in older people is accompanied by the parallel decline in the number of people in younger age cohorts. Between 2006 and 2011, there was a District‐wide reduction of

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Murrumbidgee Local Health District Renal Clinical Services Plan 2013‐2017

6. Prevalence and Demand

6.1 Chronic Kidney Disease Chronic Kidney Disease, also referred to as Chronic Renal Disease, is now recognised as a significant and rapidly growing global health burden.

Chronic kidney disease (CKD) is defined as the occurrence of kidney damage or decreased kidney function (decreased glomerular filtration rate) for a period of three or more months

(Levey et al.p.137). The most common causes of end stage kidney disease (ESKD) in Australia are:

• Diabetic nephropathy

Glomerulonephritis • Hypertensive vascular disease • reflux nephropathy

In 2012 Australia, 35% of new patients commencing dialysis had diabetic nephropathy attributed as their cause of end stage renal failure, 22% had glomerulonephritis and 14% hypertension. (ANZ Data 2012, p.xxii). Other causes of Renal Disease are; Acute injury and obstruction, renal carcinoma, analgesic nephropathy polycystic kidney disease and other genetic disorders. Chronic Kidney Disease ranges from mild kidney damage through to End Stage Kidney Disease:

Mild kidney damage may be detected, in the absence of symptoms of ill health, by blood and urine testing.

End Stage Kidney Disease is when death will occur unless essential kidney functions are replaced by either dialysis or kidney transplantation.

When a patient is screened for suspected kidney disease, a sample of urine is tested to see if protein can be detected (called proteinuria). If protein is present and no medical conditions needing treatment are evident (e.g. infection) to cause this proteinuria, urine testing is repeated approximately one week later. If this following test is again positive further testing is then undertaken to confirm the presence of kidney disease. Close management in this early diagnosis can prevent progression through the stages of kidney failure to End Stage Kidney Disease Once Chronic Kidney Disease is confirmed, the progression of it is measured by the estimating how well a patient’s kidneys are functioning, through a special blood test called the estimated Glomerular Function Rate (eGFR). The greater the eGFR reading, the better the kidneys are functioning. The stages of kidney disease, along with the eGFR readings, are shown in the graphics in Figure 6 below:

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TABLE 3: DIABETES RELATED BURDEN OF DISEASE IN MLHD

Region Diabetes Hospitalisations per 100,000

population (2010‐11)

MLHD 220.3

NSW 114.7

Source: NSW HealthStats, 2012.

The high rate of hospitalisation in the MLHD from diabetes is impacted by lack of services to assist in case management by general practice in MLHD and lack of specialist Endocrinology services. Importantly, the impact of the disease can be significantly reduced through changes to lifestyle and behaviour which would ultimately reduce the demand on medical services.

6.3 Hypertension In Australia, hypertension is recognised as being when systolic blood pressure is consistently 140mmHg or greater, or a diastolic blood pressure is consistently 90mmHg (NSW Health, 2010, p.3). Hypertension is caused by many things but describes when the arteries in the body lose elasticity or becomes narrowed and the blood has to be pushed harder by the heart to travel along the arteries. Untreated high blood pressure damages kidneys. It is currently estimated that between 25‐30% of the adult population have high blood pressure. The lack of recent population studies into blood pressure makes recent accurate estimates of the condition problematic (Australian Institute of Health and Welfare, 2010). Hypertension is a risk factor for many cardiovascular diseases and Chronic Kidney Disease. Poorer health outcomes are more prevalent when hypertension is present alongside other chronic conditions such as diabetes, renal disease, and heart failure. Hypertensive patients are a recognised high risk population for the delivery of renal care services and prevention messages, and this population group are an important sub group of people with End Stage Kidney Disease.

6.4 Aboriginal Population Aboriginal people are considered a targeted population in renal service planning because they are at a significantly increased risk of Chronic Kidney Disease, diabetes and many other chronic conditions. A shorter life expectancy is associated with the compounding negative impact of other chronic conditions. The dialysis incidence rates for Aboriginal and non‐Aboriginal populations show that for people aged 45‐64 years of age, the dialysis incidence rate is four times higher in the indigenous than the non‐indigenous population (Figure 7).1

1 The populations used are from the ABS for 2001 and the incidence figures are for years 1997 to 2006, sourced from the ANZDATA Registry

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TABLE 4: CHRONIC KIDNEY DISEASE SERVICE (PRE DIALYSIS CARE) WITH GFR <20

Unit Staffing (Full

Time Equivalent)

Total Patient numbers

Maximum Patient

Capacity * (100 per 1.0

FTE)

Wagga Wagga 0.5 46 50

Griffith Part of the outreach FTE*

42

50

Source: MLHD Renal Transitional Nurse Practitioner, 2012

6.6.2 Hospital Inpatient data (Dialysis Sessions)

The table below displays the inpatient haemodialysis admission activity at Wagga Wagga and Griffith Base Hospitals over a three year period from 2010 to 2013. The bed days include haemodialysis patients admitted directly into the Renal Ward, and those transferred into the Unit from the wards, and patients transferred in from another facility for dialysis.

TABLE 5: MLHD INPATIENT DATA 2010‐2012

Unit Admits

1/7/2010 to 30/6/2011

Admits1/7/2011 to 30/6/2012

Admits1/7/2012 to 30/6/2013

Variance 1/7/2010

to 30/6/2013

Wagga Wagga Base

3725 4686 5970 38% Increase

Griffith Base 2104 2440 2995 30% Increase

Total 5829 7126 8965 35% Increase

Source: Health Information Exchange, NSW Ministry of Health, 2013 Bed Days include Same Day Patients

In the 2011/12 period Wagga Wagga Base Hospital had an increase of 961 admissions or 21% more admissions than the previous year. Griffith Base Hospital had an increase of 336 admissions or 14% more admissions than the previous year. In 2012/13 further increases have occurred with Wagga Wagga having an increase of 2245 dialysis admissions or a 38% increase on service. Griffith Base Hospital increased the number of dialysis admissions over the two year period by 891 or 30%. MLHD as a district has increased the number of dialysis admissions by 3136, or 35% The table below identifies admitted patients with Chronic Kidney Disease receiving treatment at Wagga Wagga Base Hospital. In the 2011‐12 period, Wagga Wagga Base Hospital had an increase of 96 admissions or 27% more admissions than the previous year.

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Source: McDonald and Hurst, 2011, p.1‐2, MLHD Renal Transitional Nurse Practitioner and Renal Clinical Nurse Consultant, 2013

Two full time Registered Nurses provide an outreach nursing service for patients on home therapies care. These positions are located at Wagga Wagga and Griffith. Patients choosing to receive home haemodialysis and peritoneal dialysis must attend training to do so. The training units for these services are currently located at Royal Prince Alfred (RPA) Sydney, The Canberra Hospital, The Austin and The Royal Melbourne. Services for home training in both Haemodialysis and Peritoneal dialysis are provided at RPA, Sydney. The training is held over three days per week until completed, with the distance and cost incurred by patients and carers being significant contributing factor to the lower ratio of patients on home therapies. The table below represents current resources available to meet the current demand (Table 8). Note that the table is for both home peritoneal and haemodialysis therapies. As part of the Wagga Wagga Hospital Redevelopment, the Renal Unit will be expanded to provide 14 Haemodialysis spaces‐ 12 chairs and 2 training chairs. There will be a dedicated training zone within the unit for training and education of home therapies. The new Unit is proposed to be completed by the 4th quarter in 2014. The maximum patient capacity is provided by NSW Health Department (2007).

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As at September 2013 in Wagga Wagga there are over 700 patients cared for by one Nephrologist in collaboration with local General Practitioners. This high patient load indicates that there is demand for another nephrologist in the area. At present in Griffith there are 231 patients attending renal outpatient clinics managed by two nephrologists contracted from RPA who fly in twice per month. Table 10 shows current utilisation of Satellite / In‐centre haemodialysis services used by MLHD patients: TABLE 10: MLHD SATELLITE / IN‐CENTRE HAEMODIALYSIS SERVICES

Unit Chairs Current Patient

Numbers

Maximum Patient Capacity

Wagga Wagga^ 10 44 40

Griffith^ 6 18 24

Echuca* 6 12 24

Yarrawonga* 3 11 12

Wodonga* 9 24 36

Source: NSW Patient Administration System/ Victorian Renal Unit database, ^2013 data *2012 data

6.6.4 Renal Supportive Services There are currently 22 patients receiving Renal Supportive Services across the District. This care is coordinated primarily by General Practitioners with intermittent reviews by nephrologists as requested or required.

6.7 Projected demand for dialysis services The NSW Ministry of Health has produced renal service projections to assist LHDs in their planning. The most recent data was released in 2010, and was informed by Australian and New Zealand DATA, which is the central registry that collates all renal service related data in public facilities in Australia and New Zealand. One of the problematic issues for the collection and interpretation of renal service data is that although delivering the service is very intensive for the health service, it services a very small part of the population. Due to the small patient numbers receiving treatment, those requiring dialysis are grouped together into planning clusters, which are a geographic region made up of several towns. The planning clusters composed for MLHD are shown in Table 11.

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TABLE 12: PROJECTED INCREASE IN WAGGA WAGGA PLANNING CLUSTER

Planning Cluster

DialysisUnit

Existing chairs

2006 actual patient numbers

2011 projectedpatient numbers

2012 actual

Averageannual per centincrease 2006 to 2012

2016 projections based on actual annual variance increase

2021 projections based on actual annual variance increase

Number of chairs based on 50:50 home and

satellite/ in‐centre

Number of chairs based on 50:50 home and

satellite/ in‐centre

Wagga

Wagga

Wagga

Wagga 10 19 23 34

13.2%

52 74

6.5 @

2 shifts per day

9.2 @

2 shifts per day

All the above data includes In‐centre dialysis and home dialysis (peritoneal dialysis and Haemodialysis). A limitation of the data represented above is that the small numbers of patients who are treated, as a proportion of the population may change or alter as screening is implemented more widely.

7. Community consultation A consultation program has being undertaken from June 2012 to March 2013. The MLHD consulted with local communities, consumers, family /carers, nursing, allied health clinicians, specialist medical staff, general practitioners and other agencies with an interest in and involvement with renal health. People consulted were asked about their experiences in renal service delivery, as well as their thoughts and ideas about models of care into the future. A summary of matters raised through each forum is provided in Appendix 4. The consultation process included community members from many regions of the MLHD. Community meetings were held in Deniliquin, Griffith, Tumut, Lake Cargelligo, Hay, Hillston, Narrandera, Young and Wagga Wagga. The consultations were well attended and involved a cross section of the community, ranging from consumer groups from sites with established renal dialysis centres, interested citizens, carers of people with Chronic Kidney Disease and people with conditions that are associated with renal disease (more details from community meetings can be found in Appendix 4). In addition to these meetings, key stakeholders involved in renal services and care, from across the District and beyond, were consulted to assist in identifying issues with current service delivery models and in providing input into ways forward for renal services within the MLHD. A list of issues that emerged from these consultations, in no particular order, are shown below (bold) along with the recommendations developed in response to these issues:

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8. Discussion and Recommendations Provision of renal services across MLHD is faced by many challenges. These challenges arise from many causes, such as distance, workforce capacity, infrastructure and service feasibility. MLHD is experiencing increasing demand for renal care services and forward planning will enable to LHD to focus on health prevention, early interventions and appropriate models of care. The strategies will encompass workforce capacity, infrastructure and service models of care, and importantly will provide a plan which outlines how the disease progression can be slowed. The LHD aims to involve patients in their care by providing information and support to maximise independence and participation. The following recommendations have been formed as part of the planning process to enable the local health district to provide co‐ordinated services aimed at prevention and treatment, in the primary health and acute health context. The discussion and recommendations that follow set a basis for the development of an implementation plan. Paramount to the implementation plan will be an assessment of the feasibility of each strategy. Further analysis of some recommendations is required to determine future resourcing including funding, workforce and clinical governance. A snapshot of future services proposed arising from the recommendations outlined below is provided at Figure 9:

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8.1 Health Promotion and prevention There are a range of health promotion programs already underway in the District, the impetus for each are driven by National, state and local priorities. Health Promotion in this Plan is identified in the context of chronic disease as a whole. The lifestyle risk factors of obesity, tobacco and physical inactivity are the underlying focus of current population level Health Promotion activities, and are common across all chronic diseases including renal disease. With the development of the Population Health Plan, consideration should be given to specific needs identified in the development of this Plan and their linkages to chronic diseases such as Chronic Renal Disease and diabetes.

Health Promotion and Prevention Recommendation: 1. That the MLHD Population Health Plan (under development) describe ways to build

the capacity of health professionals to implement health promotion strategies that prevent chronic diseases, including Chronic Renal Disease and diabetes.

8.2 Primary health care The MLHD is not the sole provider of renal primary health care services. Other service providers include GPs, Aboriginal Medical Services, and private and non‐government organisations. In the context of National Primary Health Care Reform, partnerships must be further developed and enhanced in order to best meet the often complex needs of our communities.

8.2.1 Medicare Locals

Medicare Locals are primary health care organisations established to coordinate primary health care delivery and tackle local health care needs and service gaps. They have been established to drive improvements in primary health care and ensure that services are better tailored to meet the needs of local communities (Commonwealth Government, 2013). MLHD works in liaison with three Medicare Locals:

‐ Hume ‐ Loddon Mallee Murray ‐ Murrumbidgee

Medicare Local boundaries were determined by a review which took into account several factors including alignment with Local Hospital Networks (LHNs, now Districts), natural population catchment areas, configuration of health services and patient referral patterns between services (Department of Health and Ageing, 2012). The boundaries of the Medicare Locals in the MLHD are provided in Figure 10:

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Primary Health Care Recommendations: 2. That the MLHD explore a renal primary care model, to focus on prevention and early

detection / intervention and case management of chronic diabetic and Kidney disease in collaboration with Medicare Locals, Aboriginal Medical Services, General Practice staff and other providers of primary health care as appropriate.

3. That the MLHD continues to work with Medicare Locals to develop and implement education for GPs and practice nurses in renal management, with a focus on programs to address healthy lifestyle options, early identification of renal disease, the prevention of disease progression, and supportive therapy options.

4. That mechanisms to provide culturally sensitive and accessible services for Aboriginal people are identified in collaboration with Aboriginal Medical Services, and other providers of primary health care as appropriate.

8.3 Screening and early intervention Hypertension and diabetes is recognised as the major preventable risk factors which can lead to compromised kidney function. The Kidney Health Check Policy Directive (PD2010_023) focuses on screening admitted at risk patients for evidence of renal disease. Ongoing assessment and management of these patients will follow a multidisciplinary approach. The Chronic Disease Management Program has been successfully rolled out across the District. A preliminary review of those patients that have enrolled in the Program, have shown a 52% reduction in admissions to hospitals than previously and shorter hospital stays. The Chronic Disease Management Program brings a multidisciplinary approach to patients’ care with a range of medical, allied health and other services being coordinated under the program according to each patient’s individual need. Patients with renal related disease can similarly benefit from an integrated and coordinated approach to care. MLHD continues to work with General Practitioners in our region to implement the Chronic Disease Management Program. Whilst diabetes is identified as one of the priorities for enrolment to the Program, but other renal‐related diseases have not been included. Access to the Chronic Disease Management Program could be better enhanced through development of pathways with renal services, where not already in place.

Screening and Early Intervention Recommendations: 5. That pathways between the Chronic Disease Management Program and renal

services are identified and promoted for patients where eligible, using a multidisciplinary case management approach.

6. That the Kidney Health Check Policy Directive continues to be implemented across the District, with a focus on engagement of the Aboriginal community; and General Practice targeting communities of Deniliquin, Lake Cargelligo, Leeton/Narrandera and Tumut.

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8.4.3 Satellite/ In Centre Care Satellite dialysis is provided in a facility close to the parent hospital where renal nurses perform the dialysis treatment as patients are too unwell or frail to assist in their own care, or the home situation is unsuitable with no personal support available. Satellite patients in rural areas may have a higher level of dependence or medical co‐morbidities with staff having less access to medical services. Currently the staff patient ratios in Wagga Wagga are at 3.3 patients per nurse (1:3.3) and Griffith 3.5 (1:3.5) patients per nurse. The NSW Renal Service plan to 2011 (2007, p.30) state for In‐centre a ratio of 1:3 and satellite 1:4. Units in the MLHD are run with a mix of category 5 and 6, and thus have a slightly higher nurse to patient ratio to ensure no adverse outcomes for the medically unstable and multiple co‐morbid dialysis patients. For Satellite/in centre Haemodialysis currently there are; 5 patients traveling from the Young/Boorowa area to Canberra (161km), 1 patient traveling from Tubbul (26.6km north east of Young) to Orange (191km) and 2 patients traveling from Cootamundra (48.9km from Young) to Wagga Wagga (96.7km). This totals 8 patients in the region traveling 1.5‐2.5 hours one way for haemodialysis care three times per week presently needing satellite haemodialysis in the Young region. In Cootamundra there is 1 home haemodialysis patient, and 1 patient in Cootamundra that may need satellite haemodialysis care for provision of respite for carers, vascular access problems or illness. Also there are 14 pre‐dialysis patients in the Young region with an estimated 50% of these patients requiring satellite haemodialysis in the coming years A satellite / in centre haemodialysis unit in Young to service the Young, Cootamundra, Temora and Boorowa/ Harden communities is needed because the current patient data and projected growth of the region (as indicated in Table 4) indicates a need to establish a localised renal service. Patients from this area currently need to travel in excess of 1 hour for treatment and have the greatest travel times of all patients in MLHD. The Tumut, Tumbarumba, Adelong and Gundagai region currently have a total of 5 patients traveling for Satellite/in centre Haemodialysis. There are 2 patients travelling from Adelong to Wagga (1 hour 2 min – 81.1km), 2 patients travelling from Tumut to Wagga (1 hour 19 min – 101km) and 1 patient travelling from Gundagai to Wagga (1 hour 3 min – 82.4km). Currently on home therapies there are 2 patients in Tumbarumba on Peritoneal Dialysis and 1 home haemodialysis patient in Tumut. Also there are 9 pre‐dialysis patients in the region with 2 of these patients planned for satellite haemodialysis in the future. The Narrandera and Leeton region currently have a total of 5 patients traveling for Satellite/in centre Haemodialysis. There are 2 patients travelling from Narrandera to Griffith (1 hour 16 min – 96.0km), 1 patients travelling from Narrandera to Wagga (1 hour 12 min – 98.2km), 2 patients travelling from Leeton to Griffith (1 hour– 76.9km). Also there are 8 pre‐dialysis patients in the region with none of these patients planned for satellite haemodialysis in the future. The border region currently have 4 patients traveling to Echuca for Satellite/in centre Haemodialysis with 3 patients travelling from Deniliquin to Echuca (1 hour 3 min – 78.7 km)

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environment is not conducive to self‐care home dialysis therapies. The self‐care unit will be used by patients where the home environment is not suited to home dialysis. This will ensure maximum uptake of home therapy treatment. Where patients are suitable for home therapies and are able to safely dialysis in a self‐care facility with minimal support and/or supervision during their dialysis treatment (no helper) establishing helper assisted self‐care centres is warranted. This assisted self‐care model is utilised by other LHDs where a helper is provided to facilitate self‐care dialysis to provide increased opportunities for patient to dialysis closer to their homes while remaining as independent as possible.

8.4.6 Home dialysis Home dialysis therapies improve patient quality of life, empowering patient’s choices in self‐care, by providing flexibility in service delivery and by localising services. All patients need to have the opportunity to undertake their dialysis treatment at home. Therefore localised access to home training for peritoneal dialysis and haemodialysis is necessary to ensure maximum number of patients can access and take up home therapies The aim for MLHD is to have 50% of the dialysis population on home therapies. The patients are cared and supported by outreach nurses located at Griffith and Wagga in working hours. An expansion to the care of patients on home therapies with an after‐hours telephone service will ensure patients have 24 hour access to care.

8.4.7 Supportive therapy MLHD has commenced planning on the development of a supportive therapy clinical pathway, with support from the local Nephrologist. This model will use supportive therapy for renal patients and will be based on symptom assessment and management using medication and referrals to allied health services, in a collaborative care model with General Practitioners and Nephrologists. The aim is to ensure patient quality of life is preserved in the declining physical state, and to offer a supported active treatment pathway as an alternative choice to renal replacement therapies. Supportive therapy will become more coordinated, and a more viable option for renal patients in the District. It may also decrease the number of patients receiving dialysis services, as demonstrated by other conservative management Clinics which have been established by LHDs in NSW. The MLHD has developed a strategic palliative care plan focussing on a model which promotes and enables people to be cared for at home.

Disease management and supportive therapy Recommendations:

8. That the MLHD support the uptake of home dialysis to increase the number of patients receiving home dialysis treatment through: the development of haemodialysis training capacity at Wagga Wagga, and Peritoneal dialysis training at Wagga Wagga and Griffith; the provision of after‐hours telephone support; and enhancing the skill mix of staff in renal services to enable them to work across models of care. A “home first” philosophy followed by models of care that promote as much independence as possible through a tiered framework:

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Telehealth may be utilised in the areas of dietetics, pharmacology and other allied health services. This may include but is not limited to using webcam technology to liaise with patients in their home, increase access to specialists for case conferencing and education of staff and reduce travel for outreach staff.

Telehealth Recommendation: 16. That an expanded role for telehealth within the multidisciplinary management of

renal patients in the MLHD be developed.

8.5.2 Workforce Building a specialised long term renal workforce that is clinically competent and promoting the development of critical thinking/decision making is essential in to ensure optimal patient health outcomes. A renal nurse educator is crucial in the development of this rapidly expanding renal service and will contribute to the long term retention of staff and expansion of roles in this specialty area.

Workforce Recommendations: 17. That the MLHD undertake a workforce profiling exercise to identify suitable clinicians

for renal training and education to support targeted MLHD regional renal services.

18. That the MLHD review areas of renal nursing with a view to expand roles to include more patient empowerment and education to enable increased uptake of home therapies and self‐care.

19. That the MLHD examine the establishment of a Renal Clinical Nurse Educator role with allocation of future Nursing Education Funding opportunities.

20. That the MLHD provides adequate social and dietetic support for renal patients by:

working collaboratively with NGOs and Medicare Locals to provide early allied health intervention; and seeking future funding opportunities for allied health clinicians to address gaps across the healthcare continuum.

8.5.3 Transport Currently transport for renal services is provided through different mechanisms dependent on patient’s individual needs or circumstances. Many patients use private arrangements for accessing treatment. For patients who use private arrangements to travel significant distances, subsidy is provided through MLHD’s Transport for Health‐ Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS) The Transport for Health‐ IPTAAS is a financial subsidy scheme for patients who are who are able to use public or private transport and need to access specialist medical services and / or oral health surgical treatment which is not available locally. The focus of IPTAAS is for patients who are disadvantaged by distance and isolation. To be eligible for Transport for Health‐ IPTAAS, applicants must:

Be an Australian citizen/permanent resident residing in NSW (includes dual residents, itinerant workers and people of no fixed address);

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8.6 Implementation An implementation plan based on the recommendations will be developed, and should be overseen by a Working Group. In line with the District Strategic Plan (MLHD, 2012), the implementation plan should provide a vision with regard to renal services that will see:

A health service that is more responsive to the needs of patients, providing the Right Care to the Right Patient in the Right Setting at the Right Time (Models of Care);

A health service that openly engages with the people and communities it serves and works in partnership with them and other organisations to agree priorities and deliver services in a way that suits rural communities and improves health, and;

A health service that is sustainable, that has a sufficient and highly skilled workforce and that effectively manages its services within the available funding streams.

Implementation Recommendation: 25. That a Working Group of relevant clinicians and managers be established to develop

and deliver an implementation plan based on the recommendations above and that this group include consumer and carer representation.

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National Stroke Foundation 2012, High Blood Pressure and Stroke, website, viewed 4 February 2013, http://strokefoundation.com.au/prevent‐stroke/risk‐factors/high‐blood‐pressure/ New South Wales Department of Health, 2010, Revised Projections of Demand for Renal Dialysis Services in NSW to 2021. State‐wide and Rural Health Service and Capital Planning Branch. North Sydney. New South Wales Department of Health, 2010, Chronic Care of Aboriginal People‐ Model of Care, NSW Government, Sydney, Viewed 6 February 2013, http://www.health.nsw.gov.au/resources/Initiatives/chronic_care/aboriginal/pdf/CCAP_MoC_December2010.pdf New South Wales Department of Health, 2007, NSW Renal Dialysis Service Plan 2007 to 2011. State‐wide Services Development Branch, Viewed 21 September 2012, http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/155059/nswrenalplan_jan2007_final.pdf NSW Health 2010, Kidney Health Check: Promoting the Early Detection & Management of Chronic Kidney Disease, Document Number PD2010_023 NSW HealthStats, 2012, Diabetes hospitalisations by LHD, latest year, NSW Ministry of Health, Sydney. Viewed 23 October 2012, http://www.healthstats.nsw.gov.au/Indicator/dia_hos_lhn Population and Public Health Division, 2012, Population Health Priorities for NSW: 2012‐2017.NSW Ministry of Health, Sydney Yarrawonga Health, 2012, Yarrawonga Health‐ Our Services, website, Viewed 28 November

2012, http://www.ydhs.org.au/our‐services.html

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‐ Assisted Self Care ‐ Nurse Led Satellite / In‐centre

8. That the MLHD further develop referral pathways between palliative care and renal

services to improve supportive therapy models for renal patients.

9. That the feasibility of establishing satellite / in centre care at Young be explored, in collaboration with the Ministry of Health with further assessment for self‐care / assisted self‐care units to be explored at Tumut and Narrandera in collaboration with the Ministry of Health.

10. That the feasibility of expanding the existing Griffith Haemodialysis Unit be explored, in line with the MLHD Asset Strategic Plan; and with consideration to refurbishment that includes expansion of chairs and instalment of an isolation room.

11. That the feasibility of establishing self‐care capacity be explored at Lake Cargelligo and Deniliquin.

12. That as a part of Stage 3 planning for Wagga Wagga Health Service redevelopment there will be an expansion of haemodialysis chair numbers, the introduction of a nocturnal haemodialysis model of care and an ongoing commitment to the localising of home training for peritoneal dialysis and home haemodialysis.

13. That the feasibility of expansion of the District renal network be examined, in particular in relation to specialist Nephrology Services, to increase local self sufficiency of these services over time.

14. That a rotating roster for renal staff be considered, between in‐centre and home therapies settings, to build the capacity of staff in order to provide a more sustainable on‐call service.

Telehealth Recommendations

15. That an expanded role for Telehealth within the multidisciplinary management of renal patients in the MLHD be developed.

Workforce Recommendations

16. That the MLHD undertake a workforce profiling exercise to identify suitable clinicians for renal training and education to support targeted MLHD regional renal services.

17. That the MLHD review areas of renal nursing with a view to expand roles to include more patient empowerment and education to enable increased uptake of home therapies and self‐care.

18. That the MLHD examine the establishment of a Renal Clinical Nurse Educator role with allocation of future Nursing Education Funding opportunities.

19. That the MLHD provide adequate social and dietetic support by: expanding renal

allied health services in proportion with measured and expected patient growth, and

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11. Appendices

Appendix 1: Renal Clinical Service Plan Steering Committee Membership and Terms of Reference

1. Purpose The Renal Clinical Service Plan Steering Committee will oversee the development of a comprehensive Renal Clinical Services Plan to promote renal health and meet the current and future Renal Service needs of the Murrumbidgee Local Health District (MLHD) community. 2. Objectives The objectives of the Renal Clinical Service Plan Steering Committee include:

To gather and review relevant data and information to inform stakeholders

To identify priority areas of need for service development and new models of care

To support a program of consultation and engagement with communities and all key stakeholders

To make recommendations on Renal Service directions and models of care for the MLHD.

To develop a coordinated and planned approach to the provision of Renal Services in the MLHD.

Ongoing governance/oversight of implementation of plan.

3. Membership The Renal Clinical Services Plan Steering Committee will include representation from the following: • Chief Executive • MLHD Director of Nursing (Chair) • MLHD Director Operations • MLHD Transitional Renal Nurse Practitioner • MLHD CNC Renal • Renal Physician • MLHD Planner • Carer Representative • Consumer Representative • Medicare Local Representative The Steering Committee may (from time to time) co‐opt others to discuss specialty area requirements.

4. Quorum A quorum consists of half the total number of members plus one. 5. Meeting procedures

The meeting schedule will be set by committee members.

The MLHD Director of Nursing & Midwifery will provide secretariat support to the committee.

6. Time period / review

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Appendix 2: Ten Principles for Renal Care in NSW FIGURE A1: PRINCIPLES FOR RENAL CARE IN NSW

Principle Indicator

ONE: Integrated primary screening for patients athigh risk of developing CRD for early identification,assessment and treatment.

Under development.

TWO: Integrated secondary prevention programsfor Chronic Renal Disease.

1: Proportion of eligible patents with glomerularfiltration rate of <30mL/min when first seen by aNephrologist

THREE: Patients with a diagnosis of CRD receivetimely, appropriate investigation, information,treatment and follow‐up.

2: Proportion of patients commencing dialysis,whose first referral to a Nephrologist is <90 daysprior to first dialysis

FOUR: Patients with progressive CRD receive appropriate education and preparation for EndStage Renal Failure and treatment in partnershipwith health care professionals.

3: Proportion of patients who completed a pre‐dialysis education program

FIVE: Patients with CRD requiring treatment, have timely access to appropriate vascular accessservices.

4: Proportion of eligible patients commencinghæmodialysis with permanent vascular access

SIX: Patients with CRD requiring treatment, haveaccess to clinically appropriate forms of treatmenteither in home, community or hospital facilities,designed around the individual patient needs,including transplantation services where clinicallyappropriate.

5: Proportion of patients dialysed at home 6: Travel time – Proportion of patients for whomtravel time to their dialysis location is ≤ 1 hour.

SEVEN: Patients with CRD receive high quality,evidence‐based, treatment services.

7: Patient waiting times ‐ Frequency a patientcommences dialysis more than 30 minutes afterscheduled time 8: Proportion of eligible patients who receiveadequate haemodialysis (i.e. URR≤ 65%). 9: Proportion of eligible haemodialysis patientswith total weekly dialysis hours >15. 10: Proportion of eligible peritoneal dialysispatients with Creatinine clearance >50L per week(or Kt/V ≥ 1.8). 11: Vascular access infection events per 100patient catheter days 12: Number of peritoneal infections per peritonealdialysis patient‐month 13: Renal Transplant survival at 1, 3, 5 years.

EIGHT: Patients with CRD receive timely andappropriate information of end of life options or choices.

Under development.

NINE: Patients with CRD at risk or suffering acuterenal failure, have access to high quality hospitalservices in partnership with renal services.

14: Patient survival on dialysis treatment at 1, 3, 5years. 15: Patient survival after Renal Transplant at 1, 3, 5years.

TEN: Patients with CRD receive holistic careprovided by multidisciplinary teams.

Under development.

Source: NSW Department of Health, 2010, p.ii‐iv

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Prevention / Future renal patients o Emphasis needs to be more on screening and prevention o Lots of patients have co morbidities o Linking with practice nurses to assist with prevention efforts

o Concern about the renal burden into the future with so many diabetic patients o Need to plan for increased patient numbers

Service access issues (see also transport) o More services wanted closer to home o Difficulty in accessing holiday places o Limited availability of support services. o The 12 chairs proposed for the new WWBH will not be sufficient – may be beneficial

to have an acute unit in WWBH and still a satellite unit. o More nephrology services needed o Increase in number of chairs available

Staffing o Another Nephrologist in Wagga Wagga. o Chronic Kidney Disease is near a full caseload so need to plan for this position o Clinical Nurse Educator for renal unit to provide support to staff and incoming

postgraduate nurses o 1.0FTE Renal CNC position for MLHD o FTE and funding for Pharmacy support to the renal service o Social Work and Dietitian roles to be separated between Wagga Wagga and Griffith o Transplant co‐ordinator/ position to facilitate the WWHS being able to case manage

these clients both pre and post‐transplant. Need a specialised service for this. At present we are reliant upon RPA for this service and it is not as available as needed.This results in less patient’s being on transplant lists, work up time increased etc.

o On‐call Nephrology service is needed o Peritoneal dialysis training position needed o No on‐call staff for dialysis patients or on call assistance services. o No established pathway for contacting RPA out of hours o Up skilling needed‐ training needed to assist patients being looked after at home

Aboriginal health workers should be with Indigenous clients from beginning Define borders between Griffith and Wagga Wagga services in terms of geography and

who covers which areas Carers

o Additional support for carers (emotional included) o Respite services for carers needed o Time taken in travel plus waiting while undergoing treatment is significant o Holiday dialysis needs improvement‐ improved access

Better services for conservative patients Palliative care treatment for end stage quality of life

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FIGURE A10: TIME SERVICES PLOT OF NUMBER ON DIALYSIS IN MLHD

Figure 11 (left) illustrates the spatial distribution of renal patients in the MLHD, with the largest centres being Wagga Wagga, Griffith and Young. Figure 11 (right) illustrates the point distribution and the distribution is smoothed across space in Figure 11 (left).

FIGURE A11: THE SPATIAL DISTRIBUTION OF RENAL DIALYSIS PATIENTS IN MLHD

Spatial point pattern of dialysis patients in MLHD Density plot of dialysis patients in MLHD

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Conclusions from MLHD spatial analysis

The relationship between population and the prevalence of dialysis demonstrates a strong relationship. There is little evidence of global clustering across MLHD. For both these reasons it seems reasonable to accept the forecast approach of the Ministry of health. The rate of growth in dialysis demand observed in MLHD of 4.07% per annum is similar to the 4.7% per annum observed across the state. At a local level the sites which have higher than expected demand are Young, Griffith, Coolamon and Adelong. With this is mind it seems possible that expansion of services at existing locations will be able to accommodate demand. Diseases with low incidence tend to demonstrate “lumpy” spatial distribution of demand. Overcoming this “lumpiness” or the lack of divisibility of patients will require labile service provision through time across the service delivery space. As two of the identified sites (Coolamon and Adelong) are within short distance to Wagga Wagga and Wagga Wagga is relatively close to the mean centre of demand, the further expansion of services in Wagga Wagga could well be supported on the basis of equitable geographic service provision. Further disaggregation of service is likely to experience diseconomies of scale, both economically and clinically. Economies of scale arise through to indivisibility and specialisation. Both of these traits are particularly true in renal nursing staff. Due to the low‐prevalence, highly specialized and expensive nature of dialysis therapy it tends to be delivered at regional centres serving large population bases (Hinkle et al, 1968). Smaller sites away from the major centres are often referred to as satellite sites. Deleterious clinical outcome are not typically associated with satellite clinics (Diamant et al, 2010; Roderick et al, 2005; Bernstein, Zacharias, Blanchard, Yu and Shaw, 2010).

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FIGURE A3: OBSERVED AND EXPECTED NUMBERS OF DIALYSIS PATIENTS BY TOWNSHIP ACESS THE MLHD

Township Observed Count

Expected Count

Adelong 2 0.296753171

Albury 7 17.9619592

Barham 0 0.380005192

Batlow 0 0.335022245

Berrigan 0 0.300445801

Boorowa 0 0.359192187

CoolamonMPS 2 0.449493774

Cootamundra 2 1.868470759

Corowa 0 1.889283764

CulcairnMPS 0 0.375976868

Darlington 1 0.344421667

Deniliquin 3 2.494539384

Finley 0 0.689514721

Griffith 13 5.432194362

Gundagai 1 0.670715878

Hay 1 0.884888415

Henty 1 0.289703605

Hillston 0 0.353821089

Holbrook 0 0.448486693

Howlong 1 0.856354457

JerilderieMPS 0 0.25781271

Junee 1 2.031282171

LakeCargelligo 0 0.384704903

Leeton 3 2.450227824

Lockhart 0 0.28097557

Mercy_Health 0 2.289766268

Mercy_Young 0 2.289766268

Moama 1 1.11819549

Mulwala 1 0.639160676

Murrumburrah 0 0.653931196

Narrandera 2 1.329682479

Temora 0 1.371644183

The_Rock 1 0.288696524

Tocumwal 0 0.563965303

Tumbarumba 0 1.251130169

Tumut 1 1.988984773

UranaMPS 0 0.112793061

Wagga Wagga 22 15.68864192

Wyalong 1 1.037629018

Young 8 2.289766268

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Local Health District Clinical Services · PDF fileRenal Clinical Services Plan 2013 ‐2017 ... 4.1.3 National Primary Health Care Strategic ... A goal of the Murrumbidgee Local Health