Allied HealthWays - a clinical guidance website for allied health in an integrated health system.

Background and context The Canterbury health system adopted a whole-system approach towards integrated patient care. There was a need to optimise the use of allied health resources, across private and public settings. Assessment of the problem There was no common means for consensus and communication among allied health professions about consistent patient care, and barriers such as a lack of trust existed. This paper describes the implementation and monitoring of Allied Healthways, a website for allied health professionals, set up in 2017 using the HealthPathways approach. Results Over 100 pathways have been published on Allied Healthways, with >13 000 clinicians using the site in Canterbury. Targeted education sessions for allied health professionals, combined with newsletters, raised awareness of new pathways or changes in the system. A survey highlighted the usefulness of Allied Healthways, and the majority of respondents agreed that the site should be available nationwide. Strategies for improvement Development of pathways was found to be a useful mechanism for improving integration in the system. The workgroups and direct meetings engaged allied health professionals and helped achieve local consensus on pathways. They also enabled improvements to be designed and then communicated as a pathway. Lessons learnt Although the patient journey should be consistent, irrespective of their point of contact with the health system, guidance and processes need to be relevant to their target audience. It was essential to write pathways specifically for allied health professionals.

Establishing a community infusion service in Canterbury, New Zealand: strategies and lessons.

Background and context An increasing number of drugs and blood products need to be delivered by intravenous infusion. In the Canterbury region of New Zealand, these have historically been delivered at a hospital site; however, some infusions could be delivered in a community setting without compromising patient safety. Assessment of problem The Canterbury health system has a key strategic objective of delivering care close to patients' homes. In 2018, Canterbury district health board (DHB) put out a tender for a community infusion service that would deliver blood products and other intravenous drugs with appropriate medical oversight. Strategies for improvement Following an interview and selection process, a fee-for-service contract was developed with a group of general practices with partial common ownership. It was nurse-led with medical oversight available. In July 2018, a Community Infusion Service (CIS) was started in two urban sites in Canterbury. It later expanded to two more sites, one urban and one rural. Results From July 2018 to May 2021, over 3000 infusions and blood transfusions were delivered by the CIS across seven infusion types (blood; immunoglobulin; infliximab; natalizumab; pamidronate; toculizumab; zoledronic acid). Both general practice and hospital services referred patients to the CIS. No major incidents were reported. Patients reported satisfaction with the service. Lessons Infusions and blood products can be delivered safely nearer to patients' homes in primary care in a New Zealand setting. Medical input was rarely required; however, the transition was resource-intensive; it required both overall process and criteria negotiations, as well as individual patient discussions. In its initial stages, the CIS did not have adequate clinical governance and operational support, which affected the speed and scale of its development.

Achievements and challenges during the development of an advance care planning program.

A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.

Assessment of a clinical pathway for investigation of haematuria that reduces the need for cystoscopy.

AIM: To evaluate prospectively a clinical pathway for investigation of haematuria that involves an initial screening using a urinary biomarker of bladder cancer (Cxbladder Triage™ (CxbT)) in combination with either a renal ultrasound or a computed tomography imaging. Only test-positive patients are referred for specialist assessment and flexible cystoscopy. METHODS: The clinical outcomes of 884 patients with haematuria who presented to their general practitioner were reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, specialist assessment and histology. RESULTS: Forty-eight transitional cell carcinomas (TCC) and three small cell carcinomas were diagnosed in the study cohort. The clinical pathway missed a solitary, small, low-risk TCC. When combined, imaging and CxbT had a sensitivity of 98.1% and a negative predictive value of 99.9% to detect a bladder cancer. Follow-up for a median of 21 months showed no further new cases of bladder cancer had occurred in the patient cohort. Review of all new bladder cancers diagnosed in the 15 months following the study showed that none had been missed by haematuria assessment using the clinical pathway. CONCLUSIONS: The combination of CxbT and imaging reliably identifies patients with haematuria who can be managed safely in primary care without the need for a secondary care referral and a flexible cystoscopy.

An initiative to improve equity, timeliness and access to District Health Board-funded physiotherapy in Canterbury, Christchurch, New Zealand.

Background and context General practice teams frequently request orthopaedic and musculoskeletal physiotherapy. In the Canterbury District Health Board (DHB) region, before November 2018, the criteria for DHB-funded physiotherapy were unclear. Wait times were many months. Care was provided on hospital sites. Limited data were available about the service. Assessment of problem A clinical project group including private and DHB hospital physiotherapists and general practitioners was established. Patients requiring orthopaedic and musculoskeletal physiotherapy who had certain criteria were seen by physiotherapists in contracted private clinics in the community instead of by physiotherapists in hospital departments. Patients received up to NZ$300 (excluding GST) of care. A claiming process was established that required the physiotherapy clinics to provide data on patient outcomes. Results In the first 12 months of the programme, 1229 requests were accepted. Patients waited an average of 11.1 days for their first appointment. There was an average Patient Specific Functional Scale increase of 3.7 after treatment. Strategies for improvement A change environment was critical for this community-based, geographically distributed model to succeed. It was supported by key clinicians and funders with sufficient authority to make changes as required. It required ongoing clinical oversight and operational support. Lessons DHB orthopaedic and musculoskeletal physiotherapy can be moved from hospital sites to a community-based, distributed service in a timely, effective and equitable fashion. There was a prompt time to treatment. Data collection was improved by tracking 'before' and 'after' measures.

Evaluation of HealthPathways: an appraisal of usage, experiences and opinions of healthcare professionals in Australia and New Zealand.

Objectives HealthPathways, pioneered in Canterbury, New Zealand, in 2008, is a web-based tool designed to promote health care integration and patient management in primary care and to reduce fragmentation in the delivery of health services. This cross-sectional study evaluated the utilisation and perceptions of this tool among health professionals in Australia and New Zealand. Methods A cross-sectional survey was administered online through Research Electronic Data Capture (REDCap) to general practitioners (GPs), practice nurses and managers, nurse practitioners, specialist and community nurses, hospital clinicians, nurses, managers, and allied health professionals between April and September 2018. The frequency of HealthPathways use in the previous month was modelled as an ordered response using an ordered logistic regression model after adjusting for the possible effects of sex, age, years in clinical practice, location and time spent in practice. Results Health professionals perceived HealthPathways to be useful in primary care management and referral, as well as in the prereferral treatment of patients. GPs in New Zealand, New South Wales and Victoria were 73%, 47% and 27% more likely to have used HealthPathways ≥10 times in the previous month respectively. Conclusion The results suggest that HealthPathways is having a positive effect on healthcare systems in New Zealand and Australia. However, differences in uptake suggests the need for focused implementation, integration into eReferral software and expanding the tool to medical students, registrars, allied health professionals and potentially patients to encourage behavioural change. What is known about the topic? Early evaluations suggest that HealthPathways is a useful tool for health professionals, although uptake and utilisation may be limited. However, there is no comparative evidence regarding uptake and implementation of the tool. What does the paper add? This study is among the first to provide a comparative narrative of the literature assessing the implementation and uptake of HealthPathways across Australia and New Zealand. It is also among the first to compare the perceptions of allied health professionals in the use of HealthPathways across Australia and New Zealand. What are the implications for practitioners? The results of this study suggest the need for focused implementation, integration into eReferral software and expanding the tool to medical students, registrars, allied health professionals and potentially patients to encourage behavioural change.

Hospital avoidance: an integrated community system to reduce acute hospital demand.

BACKGROUND: Growth in emergency department (ED) attendance and acute medical admissions has been managed to very low rates for 18 years in Canterbury, New Zealand, using a combination of community and hospital avoidance strategies. This paper describes the specific strategies that supported management of acutely unwell patients in the community as part of a programme to integrate health services. INTERVENTION: Community-based acute care was established by a culture of close collaboration and trust between all sectors of the health system, with general practice closely involved in the design and management of the services, and support provided by hospital specialists, coordination and diagnostic units, and competent informatics. Introduction of the community-based services was aided by a clinical guidance website and an education programme for general practice teams and allied health professionals. OUTCOMES: Attendance at EDs and acute medical admission rates have been held at low growth and, in some cases, shorter lengths of hospital stay. This trend was especially evident in elderly patients and those with ambulatory care sensitive or chronic disorders. CONCLUSIONS: A system of community-based care and education has resulted in sustained gains for the Canterbury health system and freed-up hospital resources. This outcome has engendered a sense of empowerment for general practice teams and their patients.

Inclusion of a molecular marker of bladder cancer in a clinical pathway for investigation of haematuria may reduce the need for cystoscopy.

AIM: To examine prospectively the impact of adding a urinary biomarker of bladder cancer (Cxbladder TriageTM, CxbT) to a clinical pathway for investigating haematuria. METHODS: The clinical outcome of 571 patients with haematuria who presented to their general practitioner was reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, histology and specialist assessments. The data were used to model a theoretical clinical pathway that involved initial screening using CxbT in combination with imaging, and only test positive patients being referred for specialist assessment and cystoscopy. RESULTS: All patients underwent cystoscopy and 44 transitional cell carcinomas were diagnosed in the study cohort, with two low-risk cancers missed by CxbT, one of which was also not detected by imaging. When combined, imaging and CxbT had a sensitivity of 97.7% and negative predictive value of 99.8%. CONCLUSIONS: In our series, all significant bladder cancers were diagnosed by imaging and CxbT before cystoscopy was undertaken. The high negative predictive value of this clinical pathway would allow approximately one-third of patients with haematuria to be managed without cystoscopy.

Reducing hospital admissions for COPD: perspectives following the Christchurch Earthquake.

The devastating 2011 earthquake in Christchurch destroyed or badly damaged healthcare infrastructure, including Christchurch Hospital. This forced change in management of exacerbations of chronic obstructive pulmonary disease (COPD), which until that point had frequently led to admission to hospital and focused attention on providing safe community options for care. This paper describes the process of understanding factors contributing to high admission frequency with exacerbations of COPD and also describes a process of change, predominantly to healthcare delivery systems and philosophies, and the subsequent outcomes. What became clear in understanding admissions with COPD to Christchurch Hospital was that the behaviour of the patient, in the context of exacerbations, and the subsequent response of the system to the patient, led to admission being the default option, in spite of low severity of the exacerbation itself. By altering systems' responses to exacerbations, with a linked care process between ambulances, community care and hospitals, we were able to safely reduce admissions for COPD, with a sustained overall reduction in bed-day occupancy for COPD of ~48%. We would encourage these discussions and changes to occur without the stimulus of an earthquake in your healthcare environment!

A multifaceted intervention to improve primary care radiology referral quality and value in Canterbury.

AIMS: This article describes a seven-year multifaceted intervention leading to sustained improvement in primary care radiology referral quality and value in Canterbury, New Zealand, and discusses the transferability to other health systems. METHODS: Access criteria were developed with input from general practitioners and hospital-based specialists, and embedded in locally developed clinical pathways. A referral management service was created to streamline referral processes. Systems were developed to enable electronic referral and triage, and to provide visibility of prior imaging. A team of general practitioners was formed to continually review referrals relative to agreed criteria and to provide advice to referrers. Referring general practitioners were provided data and education about their referral patterns relative to their peers. A clinical audit programme was introduced to ensure quality and safety of care. RESULTS: The service achieved sustained improvements in referral quality (referral acceptance rates increased from 78% to 88%, urgent referrals reduced from 59% to 22%) and value (plain film volumes reduced by 40%). CONCLUSIONS: Sustained improvement to primary care radiology referral quality and value is achievable at scale using a multifaceted intervention. The transferability of this outcome is likely to be connected to supporting factors present in the Canterbury health system.

Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand.

Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for 'at risk' patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not 'at risk' waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist. SLEEP DISORDERS: MORE ASSESSMENTS, SHORTER WAITS WITH COMMUNITY SLEEP SERVICE: A community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region's largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital's sleep unit.

Unmet need for referred services as measured by general practice.

INTRODUCTION Unmet needs are a key indicator of the success of a health system. Clinicians and funders in Christchurch, Canterbury, New Zealand were concerned that unmet health need was hidden. AIM The aim of this survey was to estimate the proportion of patients attending general practice who were unable to access clinically indicated referred services. METHODS The survey used a novel method to estimate unserviced health needs. General practitioners (GPs, n = 54) asked their patients (n = 2135) during a consultation about any health needs requiring a referred service. If both agreed that a service was potentially beneficial and not available, this was documented on an e-referral system for review. The outcomes of actual referrals were also reviewed. RESULTS The patient group was broadly representative of the Canterbury population, but over-sampled female and middle-aged people and under-sampled Maori. Data adjusted to regional demographics showed that 3.6% of patients had a GP-confirmed unserviced health need. Elective orthopaedic surgery, general surgery and mental health were areas of greatest need. Unserviced health needs were significantly (P ≤ 0.05) associated with greater deprivation, middle-age, and receiving high health-use subsidies. DISCUSSION To our knowledge, this is the first survey of GP and patient agreement on unserviced referred health needs. Measuring unserviced health needs in this way is directly relevant to service planning because the gaps identified reflect clinically indicated services that patients want and need. The survey method is an improvement on declined referral rates as a measure of need. Key factors in the method were using a patient-initiated GP consultation and an e-referral system to collect data.

Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding?

This observational case series in 65 premenopausal women with abnormal uterine bleeding evaluated whether transvaginal ultrasound followed by saline infusion sonohysterography (SIS) prevented unnecessary hysteroscopy. Although SIS indicated that hysteroscopy was unnecessary in eight women, this benefit was offset by the invasive nature of the scan, the number of endometrial abnormalities falsely detected by SIS and the cost of the additional investigation.

Management of postmenopausal bleeding by general practitioners in a community setting: an observational study.

AIM: To evaluate the safety and effectiveness of a clinical pathway for investigation of postmenopausal bleeding (PMB), managed primarily by general practitioners. Women with an endometrial thickness (ET) ≥5mm on transvaginal ultrasound (TVUS) require either a pipelle biopsy in primary care or referral for specialist care. METHOD: Data on 241 women with PMB were reviewed retrospectively over a 5-year follow-up period. Twenty-five women were excluded as they did not satisfy PMB clinical pathway criteria. RESULTS: TVUS showed 121 women had an ET <5mm, 83 an ET ≥5mm, and 12 an endometrial polyp. In the women with ET ≥5mm, 38 had a pipelle biopsy performed in primary care, 36 were referred directly to secondary care, and 9 declined further investigations. Only 17 pipelle biopsies provided sufficient tissue, with the remaining 21 women referred to secondary care. Seven cases of endometrial cancer were identified, 4 by pipelle biopsy and 3 by hysteroscopy. Of the study cohort, 68% were managed solely by their general practitioner to the point of diagnosis, while 81% with an ET ≥5mm required management in secondary care at some stage. No further cases of endometrial cancer were identified in reviews of patient medical records and cancer registries. CONCLUSION: Community-based investigation of PMB is an alternative model of care with no evidence of additional risks to the patient. Targeted education of general practitioners on pipelle biopsies is essential to maximise the effectiveness of the pathway.

A regional programme to improve skin cancer management.

BACKGROUND AND CONTEXT: In 2008, public specialist and general practice services in Canterbury were unable to manage demand for skin cancer treatment. Local clinicians decided the solution was to develop a see-and-treat skin excision clinic staffed by plastic surgeons and general practitioners (GPs), and the introduction of subsidised excisions in general practice. This paper describes the collaboration between clinicians, managers and funders and the results and quality management measures of these initiatives. ASSESSMENT OF PROBLEM: There is an increasing incidence of skin cancer. GPs in Canterbury were unable to meet increasing demand for skin cancer treatment because some lacked confidence and competence in skin cancer management. There was no public funding for primary care management of skin cancer, driving patients to fully funded secondary care services. Secondary care services were at capacity, with no coordinated programme across primary and secondary care. RESULTS: The programme has resulted in a greater number of skin cancers being treated by the public health system, a reduction in waiting times for treatment, and fewer minor skin lesions being referred to secondary care. Quality measures have been achieved and are improving steadily. Development of the programme has improved working relationships between primary and secondary care clinicians. STRATEGIES FOR IMPROVEMENT: The strategy was to facilitate the working relationship between primary and secondary care and increase the capacity for skin lesion excisions in both sectors. LESSONS: Skin cancer management can be improved by a coordinated approach between primary and secondary care.

The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery.

In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.

Is HealthPathways effective? An online survey of hospital clinicians, general practitioners and practice nurses.

AIM: An online survey was used to determine the perceptions of healthcare professionals in Canterbury on HealthPathways, a website that provides clinical and referral information for general practice teams, relevant to locally available health services and resources. METHOD: The survey questionnaire included questions on the effectiveness and ease-of-use of the website, computer literacy and use of online clinical guidance systems. Differences in the responses between work groups were analysed using the Mann-Whitney test. RESULTS: 249/480 (52%) of general practitioners, 72/156 (46%) of practice nurses, and 43/66 (65%) of hospital clinicians completed the questionnaire. Approximately 90-95% of general practice teams considered the website was easy to use and had contributed to both an increase and improvement of care in the community, with about 50% stating that it had improved their relationships with patients and hospital clinicians. Minor concerns included the website's increasing size and prescriptive nature and that it increased the duration of a patient consultation. Approximately 60% of hospital clinicians reported improvements in referral quality and triage and working relationships with general practices since the introduction of HealthPathways. CONCLUSION: HealthPathways has achieved a high level of acceptance in both primary and secondary care, and has therefore acted as a valuable change management tool increasing healthcare integration in Canterbury.

Consensus pathways: evidence into practice.

HealthPathways is a website that provides general practice teams with guidance on clinical assessment and management of medical conditions, relevant to local services and resources. The website evolved in 2008 as part of changes towards an integrated healthcare system in the Canterbury region of New Zealand. The website differs from other clinical guidance websites as the clinical pathways are formulated by local healthcare professionals, health managers, and technical writers. This process is facilitated by a proactive group called the Canterbury Initiative. The website now contains over 570 clinical pathways, with access increasing seven-fold since 2009 (visits/mth; 1053 in 2009 vs. 7729 in 2014). HealthPathways has contributed to the delivery of more care in the community (e.g. primary care spirometry; 1443 measurements in 2014 representing one-quarter of the total number). Introduction of the website has been associated with an improvement in referral quality, more equitable referral triage, and more transparent management of demand for secondary care. Because the website provides relevant localised clinical information required during a patient consultation in an easy-to-use standardised format, it has overcome many of the barriers encountered by other online clinical guidance systems. The website has also acted as a change management tool by disseminating information required for successful integration of health services.