HEALTH MATTERS Victorian Healthcare Association ISSUE 1 [ JULY 2015
] vha.org.au
PHNs, politics and patience
Study challenges stroke treatment Search for pre-eclampsia cure How childhood trauma impacts health
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Our new Chief Executive Officer Coordinating healthcare: PHNs, politics and patience When should we mobilise patients after stroke?
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When should we mobilise patients after stroke?
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Mercy research aims to cure pre-eclampsia
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Community health left to treat fallout from trauma
Community health left to treat fallout from trauma Trauma and homeless initiative at Inner South CHS Police-clinician response eases hospital pressure Severe behaviour response teams How will hospitals be funded in the future? Mercy research aims to cure pre-eclampsia Health-Justice Partnerships Canadian study tour of community health centres Merri CHS gets in touch with its inner HIPPY
For editorial content please contact: SARA BYERS Media and Communications Manager The Victorian Healthcare Association Level 6, 136 Exhibition Street Melbourne, Victoria 3000 Australia Telephone: +61 3 9094 7777 Email: vha@vha.org.au vha.org.au Health Matters content is protected under the Commonwealth Copyright Act 1968 and may not be reproduced in part or in whole without written consent from the VHA. We welcome editorial submissions that are relevant to the public healthcare sector. Please email material and images with a minimum 300dpi to sara.byers@vha.org.au.
Cover image: Victorian Health Sector.
The Victorian Healthcare Association (VHA) is an independent, not-forprofit peak body working to improve population health outcomes through the advancement of health service delivery across Victoria. Our members include public hospitals, rural and regional health services, aged care facilities, community health services and Medicare Locals.
THE VICTORIAN HEALTHCARE ASSOCIATION
Our new Chief Executive Officer The VHA is delighted to confirm the appointment of Tom Symondson as our new CEO. Chair of the VHA Board Gary Thomas is confident Tom will build on his previous work as Acting CEO. “Tom’s experience, enthusiasm and the strong rapport he has already developed with the health sector put him in good stead to drive the VHA’s agenda in ensuring Victoria’s health services are well supported into the future.” “It is crucial that the VHA takes a prominent role in standing up for the sector at a time when the population is growing, ageing and the rates of obesity and chronic diseases are rising.”
Mr Symondson is looking forward to working with VHA members, governments and public health organisations to build on Victoria’s world-class health system and ensure it continues to be innovative, effective and sustainable. “My vision for the VHA is to ensure we do not become complacent, that we rise to the challenge of remaining relevant to the membership and supporting them to deliver health services to their local communities,” Mr Symondson said. “I also believe the VHA has a strong role in fostering innovation at the system level to meet the growing demand for healthcare in our community. “This is an organisation and a sector that I am extremely passionate about and I’m committed to the VHA projecting a united voice to government, stakeholders and the public, championing both the successes and the needs of our health and community health services.”
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Coordinating healthcare: PHNs, p It would seem reasonable to assume that co-ordination and integration are accepted, even compulsory, features of our health system. The general public may take for granted the idea that health services, GPs, dentists and allied health professionals all talk to each other and share a single record about a patient. Yet, as many of us in the sector know, this is often not the case.
In fact, a lack of co-ordination is at the root of so many of the challenges facing health providers every day, from the lack of integrated IT systems between providers to a lack of comprehensive population healthbased planning for our communities. The sector has grappled with these issues for as long as most people can remember - often with frustration, sometimes tears. And aside from the economic inefficiencies and impact on the stress levels of staff, it is ultimately health consumers who are affected. Successive governments have periodically sought to overcome these challenges, most recently with the establishment of 31 new Primary Healthcare Networks or PHNs. They are the latest in a succession of organisations tasked with co-ordination of our complex primary care system and integration with the acute sector. Back in 1992, the Keating Government established Divisions of General Practice to improve access to care, develop approaches to prevention, early intervention and chronic disease management, support integration and increase the focus on population health. Brian Howe, then Minister for Health, said of these Divisions: “Our reform strategy will end the professional isolation of general practitioners and help them to lift the standard of care for all their patients.” “[It] will provide a regional framework to improve general practice in five key areas: better after hours and home visits; a better general practice locum service; rebuilding the links between general practice and hospitals; involving general practitioners in community health advancement programs; and developing quality assurance processes for general practice.”
Much of this sounds very familiar today. Fast forward 20 years to the Rudd/Gillard Government’s staged introduction of 61 Medicare Locals. They were tasked with shifting the focus away from GPs and towards engaging and connecting the broader primary care sector, and linking it more effectively with hospitals. In opposition, the Coalition criticised Medicare Locals as a bureaucracy that was being funded at the expense of frontline services. A few short years later, the Coaltion won government and commissioned a review into Medicare Locals led by Professor John Horvath AO, a former Chief Medical Officer under Prime Minister John Howard. The Abbot Government released the Horvarth review’s findings on the eve of the 2014 Commonwealth Budget. Prof Horvarth remarked that Medicare Locals lacked ‘a clear purpose’ and had delivered ‘inconsistent outcomes’ which resulted in many patients continuing to experience fragmented healthcare.
If we accept that practitioners and health services do not always talk to each other, or coordinate the delivery of care, then it follows that getting this to occur – establishing trust, shifting entrenched behaviours, cultivating the right conditions and pulling the right levers – will take significant time and patience. It’s a bit like herding cats. In this context, Prof Horvath’s report reads like a pretty damning indictment of organisations that were no more than three years old. He recommended the establishment of new ‘Primary Health Organisations’ with the aim of improving health outcomes by integrating and coordinating health services. And so here we are, 12 months later, with six PHNs about to commence operations in Victoria. Minister for Health Sussan Ley has said that PHNs will be ‘outcome focussed’ on improving frontline services and ensuring better integration between the primary and acute care services. THE VICTORIAN HEALTHCARE ASSOCIATION
politics and patience Victoria’s new Primary Health Networks
MURRAY WESTERN VICTORIA GIPPSLAND
NORTH WESTERN MELBOURNE
EASTERN MELBOURNE
The historical backdrop against which the new PHNs have been established, coupled with the size of their catchments, will no doubt pose some hurdles going forward. But it is important to view PHNs as a new opportunity to build on the good work of the past.
Rather than dwelling on the challenges associated with maintaining local connections and understanding local health issues, why not focus on the potential for enabling true regional planning that scale brings? Expectations of all stakeholders, from Minister Ley down, are undoubtedly high. The challenge for PHNs will be to manage those expectations so they don’t share the fate of their predecessors. They also have an opportunity to deliver real change – to this end, speed of execution will be key. ISSUE 1 [JULY 2015] VHA.ORG.AU
SOUTH EASTERN MELBOUNRE
For the VHA’s part, we will be working with PHNs, hospitals, community health services and others to signal to governments (and oppositions) that PHNs should be treated as core components of our healthcare system, not merely add-ons. And the best way to signal this is to practise it. Far from making our sector more complex, if PHNs roll out as we hope, they should help make the health system simpler to navigate for consumers and providers. Against this key objective, we all have skin in the game. Because in another ten years– or even in three – is it really in the community’s interest to see them consigned to the wasteland, only for us to return to the drawing board yet again? Tom Symondson Chief Executive Officer Victorian Healthcare Association
When should we mobilise patients after stroke? Healthcare delivery must be underpinned by evidence to ensure patient outcomes are optimised, safety is considered, and that services are delivered in an efficient and effective manner. However, embedding evidence-based practice in clinical settings is complex – cultural change is required, clinical practice guidelines require review, and a general shift in clinician approach must occur. Translation of research into practice is not a new issue for health services or policy makers, where evidencebased practice must be balanced against pragmatism and cost. According to the Australian National Health and Medical Research Council (NHMRC), systematic reviews of randomised controlled trials (RCTs) are the most robust form of evidence, followed closely by properly designed RCTs. However, designing an RCT that will obtain ethics approval in a clinical setting is no easy task. In April 2015, Professor Julie Bernhardt and her research team published the results of a landmark RCT in The Lancet. A Very Early Rehabilitation Trial (AVERT) was a singleblind, multicentre, international randomised controlled trial examining the efficacy and safety of very early mobilisation after the onset of stroke. Acute stroke units are designed to provide specialist care for stroke patients, and the use of early mobilisation has long been believed to lead to improved mobility, aligned with the theory of neuroplasticity. Current clinical practice guidelines for acute stroke management are non-prescriptive and recommend ‘early mobilisation’ within 24 hours; however there is no clear definition of ‘early mobilisation’ or evidence to support this.
Acknowledging this, AVERT used a specified mobilisation dose, which was guided by a detailed intervention protocol. The study recruited 2104 eligible patients from 56 stroke units in the UK, Malaysia, Singapore, New Zealand and metropolitan Melbourne between July 2006 and October 2014. The National Stroke Research Institute (part of the Florey Neuroscience Institute of Neuroscience and Mental Health) coordinated the involvement of the Austin Hospital, Alfred Hospital, Royal Melbourne Hospital, St Vincent’s Hospital and Western Health. With a sample size more than 10 times that of previous comparable trials, AVERT was the world’s first large rehabilitation trial led by physiotherapy and nursing staff with patients recruited within 24 hours of stroke onset. Within this ground-breaking framework, AVERT produced unprecedented results by demonstrating that very early mobilisation led to reduced patient outcomes three months after stroke – in contrast with previous work by the same research group and other smaller trials. The AVERT group that was mobilised 4.8 hours earlier than the control group, and with 21 more minutes a day of mobilisation, had worse outcomes at three months’ disability. There were no differences in mortality or length of stay between groups. Director of Western Health’s Stroke Unit & Neuroscience Research Unit, Professor Tissa Wijeratne, led the Western Health research group with Stroke Nurse Practitioner Elizabeth Mackey and contributions from other stroke nurses, allied health researchers and neurology registrars.
THE VICTORIAN HEALTHCARE ASSOCIATION
“Before AVERT, evidence for early mobilisation after stroke came from three small studies including 159 patients,” Prof Wijeratne said. “Our research group will continue to collaborate with La Trobe University, University of Melbourne, Monash University and the Florey Institute to find answers to these questions in the coming months and years.” Professor Wijeratne said there were still unanswered questions, such as: • when should we start rehabilitation after acute stroke? • what should acute stroke rehabilitation consist of?
• would improved understanding of molecular mechanisms induced by early physical activity on stroke affected brain tissue hold some of the secrets behind early rehabilitation?
• why do some patients respond better to a more conservative approach while others do better with more therapy?
The National Stroke Foundation will be reviewing this ground-breaking research when its Clinical Guidelines for Stroke Management are updated.
• does an enriched rehab environment offer better outcome after stroke?
This article was written by VHA Policy Advisor Weif Yee.
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USA community health left to treat fallout from trauma Childhood trauma represents a public health crisis affecting the health and life path of approximately one in three Americans. Adverse childhood experiences occur in all types of communities, but are more prevalent low income and diverse ethnic and racial communities, which means community health centres in the United States are playing a disproportionate role in addressing the health consequences of childhood trauma across the life course. Research by the Washington State University (WSU) Area Health Education Center has found that between 40 and 45 per cent of children in low income families have multiple exposures to such experiences. WSU and the Northwest Regional Primary Care Association (NRPCA) have jointly launched the Trauma-Informed Primary Care Initiative. “While adverse childhood experiences help us understand the staggering nature of the risks that are dealt with in primary care, understanding this risk does not describe what can be done to address the problem.” says the Manager of NRPCA’s Community Health Improvement Program, Seth Doyle. “As a result, the core policy and practice demand is to develop effective models for how to provide care, given our knowledge of the impact of adverse childhood experiences.” The Trauma-Informed Primary Care Initiative has established that: • adverse childhood experiences are now the main social determinant of ill-health in the United States, where between 25 and 30 per cent of children grow up in families and communities that put their lifelong mental, social and physical health at risk • in resource-poor communities where CHCs operate, the impact of trauma is even more pervasive, with most patients at risk • complex trauma treatment principles, which recognise and respond to trauma, are adaptable to primary care settings • there is a movement towards integrating trauma treatment principles into primary care practice to address both physical and behavioural health
The impact adverse childhood experiences have on brain development and the resulting coping behaviours, which become barriers to improving health outcomes, are evidenced in more than 600 peer-reviewed studies. The Adverse Childhood Experiences (ACE) study is one of the largest investigations ever conducted into childhood maltreatment and later-life health and wellbeing, suggesting that certain experiences are major risk factors for the leading causes of illness, death and poor quality of life in the US. Harvard University research on the biology of stress now shows that healthy development can be derailed by excessive or prolonged stress responses in the body (especially the brain), with damaging effects on learning, behavior, and health across the lifespan. Further reading: Eastern Washington Area Health Education Center ext100.wsu.edu/ahec Centers for Disease Control and Prevention dc.gov/violenceprevention/acestudy Harvard University Center of the Developing Child developingchild.harvard.edu THE VICTORIAN HEALTHCARE ASSOCIATION
Trauma and homelessness initiative at Inner South CHS A study conducted through Inner South Community Health Service (ISCHS) has found a cyclical relationship between trauma, long-term homelessness, mental health difficulties and social disadvantage. Five years ago, ISCHS interviewed 985 of its homeless clients and found a significant number of them had experienced traumatic events before becoming homeless. ISCHS responded by joining forces with Sacred Heart Mission, Mind Australia, and VincentCare Victoria to commission further research by the Australian Centre for Posttraumatic Mental Health. “It looked like our client group had suffered a lot of trauma, so we were very interested in finding out the connection between that and their need for extensive services,” says ISCHS General Manager, Primary and Mental Health Alan Murnane. “We wanted to understand where the trauma sat in people’s backgrounds and how we might go about working with them. “We also wanted to demonstrate the link, which we were aware of although we didn’t have any evidence, that most people using our homeless services had at some stage faced trauma in their life.”
RESEARCH FINDINGS • Traumatic events are often a precursor to becoming homeless – many people left their home to avoid ongoing trauma such as assault, child abuse and interpersonal violence. • Being homeless is a risk for experiencing further trauma – the frequency of trauma exposure escalated when people lost their secure accommodation. • Trauma, especially that caused by a primary caregiver, impacts on a person’s sense of safety and connection with other people, and on their ability to maintain social relationships. • Trauma drives mental health problems – this client group had increased rates of psychiatric disorders and other adverse mental health experiences.
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The Trauma and Homelessness Initiative involved a literature review and qualitative interviews with 20 service users, all of whom reported experiencing at least one traumatic event in their lifetime. Staff focus groups were also conducted with 42 case workers. Finally, a quantitative study of 115 homelessness service users found that 98 per cent had experienced type I (single incident) trauma and 60 per cent had experienced type II (chronic childhood) trauma There were very high levels of exposure to interpersonal violence (including sexual and physical assault), natural disasters, and life-threatening accidents, and most participants reported exposure to multiple traumatic events. “Most of them had experienced trauma before they were homeless,” Mr Murnane says. “But the trauma they experienced after becoming homeless was much greater because, in fact, being homeless is a trauma in itself.”
DEFINING TRAUMA • Type I trauma events occur at a particular time and place and are usually shortlived, such as natural disasters, serious motor vehicle accidents, sudden death of a parent, or a single incident sexual assault. • Type II trauma events are chronic, begin in early childhood, and occur within the child’s primary care-giving system or social environment. They are usually repetitive or prolonged; may involve direct harm or neglect by caregivers; and are associated with complex and long-term mental and social difficulties. Further reading: ischs.org.au/resources/research-and-evaluation/trauma-andhomelessness-initiative-thi/#&panel1-1
Police-clinician response eases hospital pressure
Peninsula Health mental health clinician Sarah Coffey (left) and a local police officer with a client.
A joint response from police and mental health teams to people experiencing behavioural disturbance in the community is reducing the number of mental health presentations at Victorian hospitals. Police, Ambulance and Clinician Early Response (PACER) is being rolled out across Victoria following successful programs in the municipalities of Bayside, Kingston and Glen Eira and at Eastern Health, Alfred Health, Northern Health and Peninsula Health. Southern Health and Moorabbin Police started Victoria’s first PACER program in 2007, after studying similar models in the United States.
“By placing a mental health clinician in the peak of the situation, nine times out of 10 we are able to defuse the situation and treat and support clients in their own home,” mental health clinician Sarah Coffey says. “By providing an on-the-spot response we are often able to avoid the person being transferred to the Emergency Department by police or ambulance.”
Evaluation of the program found that people suffering a behavioural disturbance were less likely to present at an emergency department (ED) and that police units were released to other duties more quickly.
She and colleague Dwight Smith are clinicians in the Peninsula Health PACER program, which runs seven days a week from Frankston Police Station. They also provide a secondary response service to Frankston, the Mornington Peninsula and parts of neighbouring Casey.
State government funding was announced last year for PACER to be run by each of Victoria’s 21 Area Mental Health Services.
In addition to freeing up police and emergency department resources, Ms Coffey says it has also had a positive impact on patients and their families.
North Western Mental Health nurse Steve Brown says there has been a decrease in mental health presentations at Northern Hospital, which has one of Melbourne’s busiest EDs.
“Often, in the sort of the situations we attend, the ¬patients will feel they are in trouble and that they have done something wrong ¬because the police are there.
“People living with mental illness, who are in crisis, can be attended by trained police and clinicians in their home,” Mr Brown says. “This eases the impact on hospital emergency departments and significantly reduces the individual’s distress and anxiety.” Since Peninsula Health introduced PACER in April 2014, the number of mental health patients treated at Frankston Hospital’s ED has dropped by 86 per cent. The program has recently been extended to Rosebud, assisting 57 clients in its first three months.
“By bringing in someone in a therapeutic role rather than an authoritative role, we are able to provide support for patients and families.” “We work with people who have existing mental illness and those having acute one-off episodes. It is often a matter of de-escalating the situation, treating them and referring them into the most appropriate care. “It is better for everybody if we are able to treat people in a familiar environment where they feel safe rather than taking them into hospital unnecessarily.” THE VICTORIAN HEALTHCARE ASSOCIATION
Severe behaviour response teams Hesse Lodge Nursing Home is slightly different to the average residential home, both in design and attitude. There is an abundance of natural light; staff are present but unobtrusive; doors and windows are open; and an old ute sits out the back in a large garden, which has a workshop of tools for residents to tinker with. Run by Hesse Rural Health, Hesse Lodge has 24 high and low care aged care beds. Rural surrounds make it familiar and comforting for residents, most of whom are local people living with dementia. CEO Peter Birkett hopes that a new federal government program of Severe Behaviour Response Teams (SBRT) will not diminish the safe and welcoming environment at Hesse Lodge. The SBRT program will replace the dementia supplement previously paid to service providers and will be funded through the same allocation of $54.5 million over four years. Multidisciplinary response teams will provide expert advice to residential aged care facilities needing assistance to care for residents with severe behavioural and psychological symptoms of dementia. Initially, they will work with existing Dementia Behaviour Management Advisory Services (DBMAS) but will become fully integrated with DBMAS from 2016-17. “A funded replacement to the former supplement is very much welcomed, but we have concerns about implementation,” Mr Birkett says. “Here at Hesse we are recognised for the positive effect our environmental design has and for our staff. As a rural facility, we worry about how city-centric this approach will be to what is a large problem in many rural and regional areas. Hesse Lodge Nursing Home
“We support the investment, but the review of dementia responses also needs to include environmental design and ongoing staffing approaches. “Roaming teams of experts may work in the first instance, but building capacity through a whole-ofworkforce approach and much-needed training for staff can’t be forgotten. Ideally, we’d like to see funding for appropriate internal expertise to work with residents on an ongoing basis.” The potential for chemical and physical restraints to be used concerns Mr Birkett, as Hesse prefers to use restraint-free options for distressed residents. A comprehensive patient assessment, care planning and consent process is followed before restraints are used, in order to meet Commonwealth guidelines and mandated reporting requirements. “For people living with dementia, having familiar rather than transient staff is important. We’d like to see our current staff trained to better manage behaviours,” he says. “Essentially, we don’t want our residents waiting for necessary services due to the location of SBRT, or to have them further upset by unfamiliar faces, who may be more predisposed to administering physical or chemical restraints as a response to a resident’s further distress at a change in routine.” A recent unscheduled evaluation of Hesse Lodge by the Residential Aged Care Standards Agency reported a “relaxed atmosphere in the dementia environment with a focus on activities and meaningful engagement”. Mr Birkett says: “Hesse is a place for the people of this community to come when they need help to cope with living with dementia. We want the environment to be comfortable, safe and welcoming. We want our residents’ families to feel that when they visit too. We’ve done everything we can to run Hesse as an example of best practice, and we want to make sure SBRTs add to that not diminish it.”
ISSUE 1 [JULY 2015] VHA.ORG.AU
How will hospitals be funded in the future? Certainty must be a key feature of any future health funding agreement between the Commonwealth and the states, according to the Grattan Institute’s Health Fellow Peter Breadon. Speaking at a VHA forum after the Commonwealth Budget was delivered in May, Mr Breadon said that public hospitals needed binding or legislated agreements to ensure their future funding arrangements.
Grattan Institute’s Health Fellow Peter Breadon
“I’d like to see medium-term agreements which are certain, enforceable and linked to activity. I’d also like to see the opportunity to get much more transparency about performance at a state and provider level,” he said. “Within health, hospital funding has clearly been the fastest-growing component but current funding for Australia’s public hospital system is unsustainable. This is a big unanswered question: how are we going to fund public hospitals in the future?” To answer this question, Mr Breadon speculated on the following scenarios: • increasing state tax, which may become a necessity • increasing commonwealth funding, however reinstating previous levels of commonwealth funding is unlikely • a major shift in roles, responsibilities and/or tax revenue between the Commonwealth and the states, which is also unlikely • removing avoidable hospital costs, as identified in the Grattan Institute report Controlling Costly Care which states: “The gulf between treatments in high and low-cost hospitals in Australia is vast, with no good reason for such variation. This money is not being used to provide better care – it is simply being spent inefficiently and could be used for much better ends”. Grattan estimates that $1 billion in avoidable hospital costs could be saved nationally if state governments: • paid hospitals for treatments on the basis of an average price once all avoidable costs have been removed • made data available to hospitals so they can compare themselves to their peers and see where they can cut costs • held hospital boards to account when they fail to control costs.
“There is huge variation, which suggests that there is room for greater efficiency in the system,” Mr Breadon explained. “In future, if the Commonwealth is going to ask ‘how do we calculate a more efficient price?’. “The Commonwealth may also look for greater accountability and transparency in the system, for example, evidence for future demand growth may need to demonstrate that the demand is legitimate and the services are high-value.” Although the Commonwealth has announced reviews into primary care, the Medical Benefits Scheme and the Pharmaceutical Benefits Scheme, Mr Breadon said it was disappointing that the May budget didn’t address primary care: “There is no big picture for primary health in this year’s Commonwealth budget. They haven’t talked about Primary Health Networks or given any more detail on their funding. They haven’t talked about preventative health or chronic disease management.” He also said there was “no clear vision” for what the Medical Research Future Fund should focus on: “Let’s have some long-term, high-quality, well-funded trials of some preventative measures and healthcare delivery models – things that we can’t get the IP for from other countries, things that are more about system design and service delivery. I’d love to see us having a crack at solving some of these riddles.” THE VICTORIAN HEALTHCARE ASSOCIATION
Mercy Hospital research aims to cure pre-eclampsia In her final year of training to qualify as an obstetrician-gynaecologist, Dr Fiona Brownfoot decided to become a clinician-scientist and find a cure for pre-eclampsia in preterm pregnant women. Dr Brownfoot, 31, completed three years of clinical training at the Royal Women’s Hospital before moving to the Mercy Hospital for Women to complete her PhD under the supervision of Professor Stephen Ton and Dr Tu’uhevaha Kaitu’u-Lino.
Dr Fiona Brownfoot
Pre-eclampsia is one of the most common complications of pregnancy, affecting between five and eight per cent of pregnant women. It occurs when the placenta releases toxins into the mother’s blood stream, causing widespread damage to her blood vessels and often leading to multisystem organ damage. There is no treatment for pre-eclampsia – the only way of stopping it is to deliver the baby, which carries minimal risk at the end of a pregnancy. But at preterm, the disease leads to high rates of infant morbidity and mortality. Dr Brownfoot is researching the safety and efficacy of treating pre-eclampsia with Pravastatin – a cardiovascular medication that is widely used to reduce high cholesterol. “Animal models suggest that it may be able to stabilise pre-eclampsia and we’ve further investigated its effects on human tissues with very encouraging results. Our main goal is to find a medical therapeutic that might allow mothers to extend their pregnancies until it’s safe to deliver their babies,” Dr Brownfoot says. “I’ve always had a real interest in research, inspired by my clinical work. Even now, very little is known about some of the most common obstetric complications, including pre-eclampsia, and there are very few medical treatments for them. Research on these conditions can have a big impact on improving outcomes for our women and babies.”
“Our lab-based studies and our clinical trial on pravastatin are looking really promising. We’ve recruited four women so far. They were really excited about the potential and the hope that we may be able to come up with a treatment.” “Together we hope we’ll be able to make a difference for them, for other women and for their children. The outcomes could give women a much brighter future in terms of their own health and that of their babies.” The study needs to recruit eight more women from 23 weeks gestation who have pre-eclampsia. “If we are able to treat the pre-eclampsia in these preterm women then we might be able to get better perinatal outcomes. Every day really counts at this early stage of gestation in pregnancy.” Similar trials are underway in the UK and US but both these studies are still recruiting and have not released any results yet.
Other research has focused on preventing preeclampsia with vitamins C and E, and aspirin. While aspirin has been shown to reduce the incidence, vitamins were found to be ineffective.
Dr Brownfoot won the Laxmi Baxi award for outstanding research at the Society of Reproductive Investigation in San Francisco in April 2015, and the ISSHP president’s award at the International Conference for the Study of Hypertension in Pregnancy in New Orleans in 2014.
“There are ongoing studies on heparins and, more recently, on pravastatin as a possible medical therapeutic,” she says.
She has amassed 11 journal articles, attracted $180,000 in research funding during her PhD and won a number of New Investigator Awards.
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Health-Justice Partnerships There is growing recognition in Victoria of the importance of providing holistic, multi-disciplinary care to the most vulnerable and disenfranchised people in our society, to ensure they do not fall through the safety net. Legal services that are integrated into health settings are an important part of this multi-disciplinary approach, because legal needs are considered one of the social determinants of health. This was recognised by the Legal-Australia Wide Survey (the LAW Survey) conducted in 2012, which found that legal problems often have negative impacts on many life circumstances including health, financial and social circumstances.1 Integrating legal services into healthcare settings allows clinicians to provide wrap-around care to their patients, and builds on existing research into advice-seeking behaviour. Known in Australia as Health-Justice Partnerships, these integrated services are based on Medical-Legal Partnerships, which currently exist at 276 healthcare institutions across the United States (US).2 This model is gaining momentum in Australia, with several partnerships now in place at hospitals and community health centres. Inner Melbourne Community Legal (IMCL) has established partnerships with the Royal Women’s Hospital (the Women’s), the Royal Children’s Hospital and Inner West Area Mental Health Services. At the Women’s, IMCL has provided almost 300 instances of free, on-site legal advice on birth certificates, family law and child support, child contact and divorce, family violence and fines. On-site legal services provide a direct referral pathway for clinicians whose patients raise legal questions. It is hoped that by breaking down the silos between health, social and legal professionals, Health Justice Partnerships will bring about greater access to justice as well as better health outcomes for individuals in our community.
THE EVIDENCE • The 2012 LAW Survey found that legal problems caused physical ill-health in 19 per cent of cases; stress-related illness in 20 per cent of cases, and that disadvantaged people “are particularly vulnerable to legal problems, including substantial and multiple legal problems”. The survey found that people seek legal assistance from non-legal advisers in approximately 69.7 per cent of cases and they seek to resolve their legal issue by consulting health or welfare advisers in 27.2 per cent of cases.3 • LegalHealth surveyed 51 cancer patients and found that legal assistance led to a significant reduction in stress for 83 per cent of respondents and an improvement in the financial situation of 51 per cent of respondents.4 • A US study at St Luke’s Roosevelt Hospital found that asthma patients who received legal interventions had “significant improvements in the severity of their condition, and fewer emergency room visits, than patients who did not receive legal assistance”.5 • A Robert Wood Johnson Foundation survey of 1000 physicians found that 85 per cent believed “unmet social needs are directly leading to worse health” and 80 per cent were “not confident in their capacity to address their patients’ social needs”.6 This article was written by IMCL Senior Project Manager and Lawyer, Linda Gyorki, who will host a workshop at the VHA Rural and Regional Forum on Thursday 6 August. Bookings: vha.org.au/events Linda is a Churchill Fellow, whose research into the practical and ethical barriers of integrating legal assistance into a healthcare setting is available at: churchilltrust.com.au/fellows/detail/3816/Linda+Gyorki Footnotes: 1 Christine Coumarelos et al “Legal Australia-Wide Survey: Legal need in Australia” (Report, Law and Justice Foundation of New South Wales, August 2012) xvi-xvii. 2 National Center for Medical-Legal Partnership http://medical-legalpartnership.org 3 Coumarelos et al, above n1, 135. 4 Wendy Parmet, Lauren Smith & Meredith Benedict, “Social Determinants, Health Disparities and the Role of Law” in Elizabeth Tobin Tyler et al (eds), Poverty, Health and Law: Readings and Cases for Medical-Legal Partnership (Carolina Academic Press, 2011), 26. 5 R Retkin et al., “Medical-Legal Partnerships: A Key Strategy for Mitigating the Negative Health Impacts of the Recession”, Health Law, 22 (2009): 31 in Parmet, Smith & Benedict above n.17, 26. 6 Daniel Atkins, Shannon Mace Heller, Elena DeBartolo and Megan Sandel, “Medical-Legal Partnership and Healthy Start: Integrating Civil Legal Aid Services into Public Health Advocacy” (2014) 35(1) The Journal of Legal Medicine 195, 199. THE VICTORIAN HEALTHCARE ASSOCIATION
CASE STUDY The Women’s referred Kate* to a lawyer at IMCL. She was in a violent relationship and had been assaulted by her partner while pregnant. She was physically assaulted, falsely imprisoned, and threats to kill had been made to Kate and her unborn child. She reported the incident to police, who applied for an intervention order on Kate’s behalf. Kate stayed away from her partner for a time, but after he made assurances that it would not happen again, she returned to him because she was pregnant and felt there was nowhere else to go. Kate applied for a variation to the intervention order to allow her partner to see and contact her. However, several days later, her partner was again violent and abusive, this time in front of her friend’s children, which prompted Kate to take action.
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When IMCL first met Kate, she had recently given birth. IMCL helped her to withdraw her variation application, so that a full intervention order remained in place. IMCL also advised Kate on how to add her child to the intervention order. The Department of Human Services had contacted Kate over concerns for her child’s safety. IMCL advised Kate on how to work with the department to ensure they both remained safe and together. The department subsequently closed its file, satisfied that Kate was taking all available measures to protect her child. IMCL also helped Kate apply to the Victims of Crime Assistance Tribunal for financial assistance to help her recover from the crime. Within four months, the Tribunal awarded Kate a lump sum of special financial assistance, approval for counselling, installation of a security system, remedial massage and self-defence classes. In total, Kate received almost $9,500 in financial assistance. * name has been changed to protect identity
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Canadian study tour of community health centres In the space of 10 days, Lynne Raskin caught six flights, visited eight community health centres, presented at a national conference, met with the Victorian Department of Health and Human Services, participated in a primary and community health roundtable, explored two cities and finally learnt how to make a smoothie in a blender powered by a bicycle she rode herself. Lynne Raskin is CEO of South Riverdale Community Health Centre (SRCHC), providing primary care and health promotion programs in Toronto, one of Canada’s most populated and linguistically and culturally diverse cities. She joined US and Canadian delegates on a whirlwind 10-day study tour of Victorian community health services in April. Hosted by the Victorian Healthcare Association and Community Health Australia, the tour facilitated information sharing on local approaches to chronic disease management, community governance and engagement, and the integration of primary healthcare with social services. SRCHC offers several dedicated Chinese language services, including a cancer support group, breast feeding consultants as well as nutrition and diabetes counselling. “We are currently working on nurse practitioner-led clinics to integrate the services our communities need, in their first language,” Ms Raskin says. “A nurse practitioner offers a different approach to a doctor – they explain things in layman’s terms and provide holistic care and social support with less expense for the patient and for our organisation. “We at SRCHC think that health must cross several boundaries; we aren’t just concerned with acute illness, but also with social support, health prevention programs and holistic care that suits each individual. Inclusive and accessible healthcare is our mission.” The study tour included a visit to Leichhardt Women’s Community Health Centre and its satellite site in Lakemba, western Sydney, where Ms Raskin and her fellow delegates were able to compare their experiences of working with culturally and linguistically diverse communities. “It was fantastic to meet people who are interested in the same topics and providing the same style
US and Canadian community health delegates from left: Bruce Gray, Michelle Jester, Bill Davidson, Simone Thibault, Lynne Raskin, Hersh Sehdev, Anita Monoian and Doug Smith.
of care, conscious of social determinants and respectful of individual needs. The services and outcomes at Leichhardt Women’s provided insights we can take home.” In Victoria, the tour included visits to Ballarat Community Health Centre, Merri Community Health Services, Aboriginal Medical Services Redfern, Inner South Community Health Services, Cohealth, ISIS Primary Care and EACH. Ms Raskin also presented at the Australia Centre for Healthcare Governance conference in Melbourne. “In Canada we are working hard to maximise our organisation’s skills, which requires critical thinking and research. Critique can lead to pride in what you do; it drives staff development and brings about positive change, which improves the health outcomes of our community,” Ms Raskin says. “We need to be continuously exchanging ideas, learning and improving our services. This study tour has been a great opportunity to share with people committed to caring for their communities, through healthcare and social support.” The VHA would like to thank the Canadian Association of Community Health Centres, the United States National Association of Community Health Centres and the International Federation of Community Health Centres for helping to facilitate the tour. THE VICTORIAN HEALTHCARE ASSOCIATION
Merri Community Health Services HIPPY program Merri Community Health Services (MCHS) provides health and social support services to the diverse and culturally rich communities across northern metropolitan Melbourne. Its Home Interaction and Program for Parents and Youngsters (HIPPY) targets disadvantaged children and families in Fawkner and surrounding suburbs. Funded by the Commonwealth and administered by the Brotherhood of St. Lawrence, HIPPY is a free homebased literacy and early childhood enrichment program for preschool children aged four and five. It aims to: • maximise the chances of a successful early school experience for children • empower parents to be their children’s first teacher • foster parent involvement in school and community life • aid children and families who speak another language at home The program empowers parents with educational tools, story books and targeted learning strategies to support their children in preparation for school. “HIPPY is one of the most outstanding programs for ensuring that disadvantaged youngsters get a good start in school, and that’s because it involves parents in the process,” Brotherhood of St Laurence Executive Director Tony Nicholson says. Since its commencement in 2008, HIPPY Moreland have had an average of 30 families per two-year cycle and are currently working with 60 families in Fawkner and surrounding suburbs. Many of the families come from India, Pakistan, Sri Lanka and Bangladesh. HIPPY Moreland has engaged 15 home tutors since 2008 and currently has five home tutors, who between them speak six different languages; Urdu, Hindi, Punjabi, Marathi, Tamil, Arabic and English. “We have seen families successfully complete the program and have had various parents employed as HIPPY home tutors after their child’s involvement in the program,” General Manager, Family and Community Support Services Tassia Michaleas says. The benefits for participating children include: • encouraging a love of learning • maximising chances of enjoyment and doing well at school ISSUE 1 [JULY 2015] VHA.ORG.AU
• promoting language and listening skills and developing concentration • building self-esteem and confidence in learning • improving communication between parents and children. Positive outcomes for families include: • creation of positive learning environments at home and an overall positive impact on family relationships • increasing parents’ knowledge of child development and the way children learn • providing parents with opportunities to enjoy positive time with their children • enabling parents to be actively involved in their children’s education • supporting parents through HIPPY tutors to develop new friendships and promoting a sense connectections with their community • increasing caregivers’ self-confidence in parenting • creating employment and training opportunities for caregivers who become home tutors
Annual Conference 8-9 October 2015 Champions for Change Our 2015 Annual Conference Champions for Change will celebrate the great achievements made by healthcare change agents over the past year. Keynote Speaker Dr Karen Hitchcock and other health sector leaders will share their change stories to inspire discussion about how we should be servicing our community’s healthcare needs today and tomorrow. Dr Hitchcock is a staff specialist in acute and general medicine at the Alfred Hospital, holds a PhD in Literature, and is an award-winning writer. In her Quarterly Essay published in The Monthly she writes: “The elderly, the frail are our society. They are our parents and grandparents, our carers and neighbours, and they are every one of us in the not-too-distant future. They are not a growing cost to be managed, or a burden to be shifted, or a horror to be hidden away, but people whose needs require us to change.” The VHA Annual Conference will be hosted on Thursday 8 and Friday 9 October at the Pullman Melbourne on the Park.
Rural and Regional Forum 6 August 2015 Empowering health services and their communities to set the agenda The VHA will host a Rural and Regional Forum for health and community care professionals on 6 August. Federation CEO of the Royal Flying Doctor Service of Australia, Martin Laverty, will open this event at the Novotel Forest Resort, Creswick. He will be joined by Chief Executive of Patient Opinion Australia, Michael Greco, and Inner Melbourne Community Legal Senior Project Manager and Lawyer, Linda Gyorki, in a panel Q&A session titled ‘Improving health outside of healthcare’. Other speakers will include Health Purchasing Victoria Chief Executive Megan Main, Timboon & District Health Service CEO, Gerry Sheehan and Executive Director of Residential and Clinical Governance Services at Ballarat Health Services, Sue Gervasoni.
Please visit vha.org.au/events for information on these and other VHA events