Health matters october 2014 by Victorian Healthcare Association

HEALTH MATTERS Victorian Healthcare Association ISSUE 2

[

OCTOBER 2014

] vha.org.au

Robot-assisted surgery improves health outcomes Healthcare on the streets of Melbourne Why we must discuss death and dying Caring for older Victorians with HIV 1

This issue… 3 4 5 6 8 9 10 11 12 14 15 16

CHIEF EXECUTIVE’S MESSAGE Time and patience will allow us to see change YOUTH PROJECTS Primary healthcare on the streets of Melbourne PETER MACCALLUM CANCER CENTRE Faster recovery after robot-assisted surgery

Primary healthcare on the streets of Melbourne

ROYAL DISTRICT NURSING SERVICE HIV epidemic has tested carers’ moral courage SPIRITUAL HEALTH VICTORIA Finding hope and purpose with age THE GRATTAN INSTITUTE Why we need debate on death and dying BALMORAL BUSH NURSING CENTRE Remote director brings new skills to bush board VICTORIAN HEALTHCARE ASSOCIATION VHA Annual Award Winners 2014 VICTORIAN HEALTHCARE ASSOCIATION VHA Annual Award Finalists 2014 BENDIGO HEALTH Bendigo midwives work in Delhi slums UNIVERSITY OF MELBOURNE COLLABORATION Obesity impacts hospital planning and patient care CENTRAL GIPPSLAND HEALTH SERVICE Clients regain skills and remain out of hospital

Annual Award Winner: Western Health

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 Facsimile: +61 3 9094 7788 Email: vha@vha.org.au www.vha.org.au The VHA would like to thank member agencies and supporters for supplying many of the photos included in this edition. This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior permission from The Victorian Healthcare Association and inquiries concerning reproduction and rights should be addressed to the editor. © The Victorian Healthcare Association Ltd 2014.

The Victorian Healthcare Association (VHA) is the major peak body representing the interests of the public healthcare sector in Victoria. Our members are public hospitals, rural and regional health services, community health services and aged care facilities. Established since 1938, the VHA promotes the improvement of health outcomes for all Victorians, from the perspective of its members.

Cover image: Peter Mac’s da Vinci® surgical robot.

This publication is printed using eco-clean print processes by Southern Colour (Vic) ISO9001 / ISO14001 & AS/NZS 4801

TREVOR CARR VHA CHIEF EXECUTIVE

Chief Executive’s Message

During my time with the VHA, Victoria has been served by three health ministers and Australia by four. I often reflect that in the VHA’s ongoing advocacy work for change in the healthcare system, Leo Tolstoy’s observation in War and Peace rings true: “The strongest of all warriors are these two – Time and Patience”. If we try to identify change on a year-byyear basis it seems that little progress has been made, but if we look across five or ten years we can see that the opposite is true. The VHA has successfully gained a commitment from the current Victorian Government to a 10-year health plan. The Victorian Health Priorities Framework 2012–2022 is an excellent point of reference to guide policy initiatives over a period long enough to implement sustainable change. Our policy platform for the forthcoming Victorian election reflects strategic approaches to address the following issues: •

effective systems that respond to the needs of an ageing community with multiple chronic comorbidities

Time and patience will allow us to see change •

funding models that enable the timely application of capital to changing service models

•

workforce models that reflect the combined capacity of a range of professional inputs

•

information systems that enable systematic flow of both clinical and business intelligence

•

research that informs system change

•

system measures that focus on outcomes, rather than outputs

Effective change requires the commitment of policy makers, advocacy bodies and service providers. I believe the future will require more strategic partnering than is evident today, as an informed public rewards service providers who demonstrate robust clinical governance systems and consistently high clinical outcomes. Fiscal pressure will also necessitate ongoing review of the most effective ways to service the core business of healthcare. Shared service centres may be one way to overcome this challenge.

As outgoing Chief Executive of the VHA, I can reflect favourably upon the company that was and the company that is today.

own. Members’ needs are also reflected in the investments we make in research, professional development, and creating tools that enable their success. To this end, the development of the Australian Centre for Healthcare Governance has been a significant investment to ensure that the responsibilities associated with directorship of a public health or community health service are supported now and in the future. The ACHG self-evaluation tool and early benchmarking work derived from it have been instrumental in guiding advocacy for further investment in director training. The qualitative analysis contributed by directors has been confirmed by research conducted with the University of Melbourne and the Victorian Managed Insurance Authority, exploring the varying approaches of boards to their clinical governance responsibilities. I believe the VHA’s work on population health approaches to planning has influenced the common use of this lexicon in policy conversations around Victoria. In time, our Population Health 101 tool will be refreshed to ensure that it remains relevant.

I believe our current structure and membership truly reflect the fact that we are here because of and for our members.

The creation of Community Health Australia and our engagement with the Australian Health and Hospitals Association to mutually advance the importance of community health in policy debate will realise future benefits.

The process for electing the VHA board is now determined by our membership as a whole. In my view, this is a fundamental right that members must

I leave the VHA satisfied with my contribution and wish our members and all associated with our work every success in the future.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Youth Projects

Primary healthcare on the streets of Melbourne

A 40 per cent rise in homelessness in Melbourne’s CBD has created unprecedented demand for support services at the Living Room primary health clinic in Hosier Lane. Run by Youth Projects, the Living Room delivers over 5,000 episodes of free healthcare to homeless people each year. Melbourne City Council’s 2014 Street Count survey in June found 142 homeless people sleeping rough – an unexpected 40 per cent increase since the previous count in 2012. According to the survey results, homeless people in Melbourne are predominantly single, Australian-born males. On average, a third have been homeless for more than five years, and many for more than a decade, suggesting the presence of a consistent group of 40 to 50 long-term homeless men in the CBD. Around a third sleep openly on the street and a quarter in squats, while others sleep in train stations, public toilets, car parks and building foyers. Most sleep in one location, or move between two or three places over a month. Around three-quarters have contact with the service system, but mainly for subsistence services such as meals and emergency relief centres. Youth Projects Chair Melanie Raymond says these figures suggest clients are using services for survival, not as a pathway out of homelessness. “Often the people we support have undiagnosed chronic illness, no care plan or support, and we are the first to provide an avenue for assistance. We are also helping reduce pressure on emergency departments as illnesses, particularly infections, are caught early,” Ms Raymond says. “The very high incidence of skin infections has been one of our major findings. Dispatching insect repellent via our outreach teams was a simple step to address infection from bites.” 4

Children deliver blankets for the homeless at the Living Room clinic in Hosier Lane.

Demand on the Living Room peaked in July 2014, as winter coughs and colds added to the challenges faced by Melbourne’s homeless population. The clinic offers general practitioner care, pharmacotherapy, mental health nursing, alcohol and other drug counselling, optometry, podiatry, and a trial dental service with onsite employment and training. Its modified sports programs and nutrition programs also provide psycho-social interventions and health promotion. “Both the long-term homeless and newly homeless rely on our GP service, showers, laundry and internet,” Ms Raymond says. “We’ve worked to put multiple supports in one place so we’re adding maximum value to the infrastructure we already have.” Last year, Youth Projects and the Inner North West Medicare Local introduced an after-hours primary care program to provide ‘pavement healthcare’ to the homeless late

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

at night. To their knowledge, the only other pavement health services in the world are in San Francisco and Vancouver. The Melbourne program operates every day and night of the year, and its foot patrol has delivered more than 1029 episodes of care on the street, under bridges, in laneways and in squats, including 400 episodes involving mental health support. “We’re always finding new supports, such as our partnerships with Hearing Voices Victoria which started this year,” Ms Raymond says. “This weekly group is the only one of its kind in the CBD and it allows voice hearers to connect and support one another.” Melanie Raymond has been named one of Australia’s 100 most influential women by the Australian Financial Review and Westpac. She is also Chair of Opportunities for Carlton, Chair of the Australian Institute of Company Directors Not-For Profit Advisory Committee, and a Director of the Inner North Community Foundation. More information: youthprojects.org.au

Peter MacCallum Cancer Centre

Surgeons from the Peter MacCallum Cancer Centre have reported data from more than 5,000 Victorian men, showing that robotic-assisted prostate cancer surgery gets patients home faster with less need for follow-up treatment. Concurrent analysis indicated that making the technology available to patients in high-volume hospitals across the public health system would be cost-effective. In identifying new efficiency savings, the study has challenged Victoria’s activity-based funding model in a specific setting. Director of Robotic Surgery at Peter Mac, Associate Professor Declan Murphy, presented findings of the three-year analysis of Victorian public and private open and robotic-assisted procedures at the American Urological Association Annual Meeting in Orlando, United States.

Faster recovery after robot-assisted surgery maintaining this equipment becomes financially viable over the operational lifespan, due to consistent savings in hospital bed days and blood transfusions. “Our statistical approach to this analysis is important because, in factoring in efficiency savings, it challenges the prevailing activitybased funding model common across many health systems in developed economies, which allocates a set cost to procedures based on their disease related group. This set cost is often based on data that is out of date.” In addition to men with prostate cancer, Peter Mac offers robotic-assisted surgery to select patients with cancer of the kidney, rectum, chest, head and neck regions. The hospital’s Director of Cancer Surgery, Professor Alexander Heriot, said global health benefits described in the

research supported the broader strategic introduction of surgical robots in Victoria. “This study shows there is scope to establish up to three further high-volume centres for robotic-assisted surgery in Victoria, enabling more patients to benefit from the comparable advantages of this cutting-edge approach, while also benefiting the treating hospital and the public health system at large through cost savings.” The study was undertaken by uro-oncology Research Fellow at Peter Mac, Dr Marnique Basto, for her Masters in Surgery thesis at the University of Melbourne. The evaluation project was funded by the State Government’s New Technology Program and Peter Mac’s da Vinci® surgical robot was funded through generous philanthropy.

Data showed the average hospital stay after a robotic-assisted radical prostatectomy was 1.4 days, compared to 4.8 days for an open procedure, with 85 per cent of men being discharged the day after surgery. Assoc Prof Murphy said men who had a robotic-assisted radical prostatectomy also enjoyed better health outcomes. Of the 284 men who underwent a roboticassisted procedure at Peter Mac, none required a blood transfusion, compared with 15 per cent of conventional surgery cases elsewhere in the public system. “Men having an open procedure also had a one-third greater chance of cancer remaining on the fringes of excised tissue which, in turn, makes them five times more likely to require additional cancer treatment in the 12 months following surgery.” Assoc Prof Murphy said, in addition to consistent health benefits, the cost of implementing robotic-assisted surgery became a net positive to the public health system in hospitals that conducted more than 140 procedures a year. “A tipping point can be reached in larger centres as the cost of commissioning and

Assoc Prof Declan Murphy with the surgical robot.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Royal District Nursing Service

In the early 1990s, I worked at Fairfield Infectious Diseases Hospital in Melbourne as a novice registered nurse. This was at the height of the AIDS epidemic in Australia, with the greatest number of deaths occurring in 1994. Fairfield Hospital was renowned for its care of people living with HIV (PLHIV) but it closed in 1996. What struck me was the confident, assertive, compassionate way that nurses dealt with complicated, confronting ethical issues and how they seemed to mostly, if not always, get it right. The issues they faced ranged from policy and practice to protecting privacy and confidentiality, supporting patients around HIV and sexuality disclosure, handling contact tracing issues, mentoring students and medical staff to reduce fear, advocacy for people on trial drugs, and supporting people’s end-of-life decisions. I submitted my PhD on nursing ethics and HIV in 2001 and two days later began working at the Royal District Nursing Service (RDNS) as a Clinical Nurse Consultant with the HIV Program. What has kept me in this clinical role has been the feeling of being at the cutting edge of the HIV sector, where nursing ethics practice at its best can make a difference for PLHIV every day.

HIV epidemic has tested carers’ moral courage It’s true that the HIV epidemic has tested the moral courage of health professionals “in ways that no other public health crisis has”. (Reamer, 1991) Many nurses stepped up to provide non-judgmental care in the face of homophobia and panic.

Australia’s response to HIV has been

But some did not. Recent local examples include an ill positive woman being rudely told to clean up her own blood after collapsing in a hospital bathroom, disclosure of an elderly gay man’s HIV status to his daughter by a nurse, and midwives refusing to pick up a woman’s newborn baby.

national response.

“Many nurses stepped up to provide nonjudgemental care in the face of homophobia and panic.” Still, HIV activism raised the bar in healthcare and has served as a model to address health inequalities globally. For the first time in history, according to Jonathan Mann (1999), global strategies for infectious diseases control incorporated positive efforts to protect the rights of those infected. It was understood that discrimination and human rights violations were “a root cause of the epidemic rather than a tragic consequence of it” (Mann, 1999).

described as ‘enlightened pragmatism’. A key element was the partnership approach, where socially marginalised groups including gay men, injecting drug users and sex workers were involved in the Other key elements included: •

law reform to prevent discrimination on the grounds of sexual orientation or HIV-status. This enabled effective peer-based education on prevention.

•

a harm minimisation approach to drug use, including needle and syringe exchanges and the rapid expansion of methadone programs.

The partnership approach was the most radical element, with affected communities demanding then shaping public health responses. This approach reflected on HIV nursing ethics and helped to inform nursing responses globally. Nurses have been deeply involved in these partnerships. One local example is the 24year partnership between the RDNS HIV Program and the Victorian AIDS Council. RDNS is a community nursing organisation whose HIV Program was established in 1986 to provide 24-hour clinical nursing, volunteer education and training, and HIV care coordination in the community. The VAC is a community-based organisation born of gay community social and political activism in 1983, which provides volunteer support, financial help, legal advice, counselling, needle and syringe programs, and a HIV clinic. Our unique partnership enables strong nursing involvement in structural advocacy. This enhances engagement and connection with services, providing a safety net for those who are most marginalised. It can also serve as a model

Victorian AIDS Council’s John Hall and Dr Liz Crock of RDNS at a World AIDS Day event.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

in other settings.

Our HIV nurses took a proactive ethical approach. By proactive ethics I mean anticipating and preventing harms to PLHIV, not just reacting to the appalling acts of discrimination experienced by many. In a recent evaluation, we asked PLHIV what they value most about the HIV Nursing Program. Their most powerful responses were about ethics. Consider this quote from a female client: “It’s a protection for us, it alleviates a lot of stress and concern. You give us a quality of care that we wouldn’t necessarily have without you, confidence in accessing services where we know that there is not going to be any issue about how we’re dealt with and to me that’s huge.

THE DEMOGRAPHICS OF HIV More than 31,000 Australians have been diagnosed with HIV since 1982 and 6,837 of these people had died by January 2012. While most people living with HIV (PLHIV) are on effective antiretroviral therapy, some experience poor health outcomes, late diagnoses, and multiple co–morbidities. There is evidence that HIV infection rates in Australia have risen to the levels of the mid-90s – with an eight per cent increase recorded in 2012, after rates had been stable for the previous four years.

“You advocate for us, you’re well informed, you’re not only educating other people about HIV but you’re also educating us about some of the issues.

The epidemic demographics are shifting, and include more long–term survivors, more people from refugee backgrounds, and more women, mostly from high prevalence countries or who have contracted HIV from other people from high prevalence countries.

“We know a lot of HIV positive people don’t ask questions of anybody – they’re living in fear of things they don’t have to be worried about – and you guys are part of giving them information to make them live confidently.”

HIV clients are also getting older. In Victoria, the proportion of PLHIV aged over 55 has increased from 2.7 per cent in 1985, to 11.2 per cent in 2000 and 25.7 per cent in 2010 – with a further rise predicted to 44.3 per cent by 2020.

This simple narrative epitomises the profound impact of a proactive ethical approach by nurses. It illustrates trust, empathy, respect, justice, confidentiality, advocacy and empowerment.

Research indicates that older people with HIV have multiple co–morbidities,

While tremendous advances have been made – we talk of treatment as prevention, pre-exposure prophylaxis, a possible cure, and an AIDS free world – some people are being left behind. In Australia, they may be long-term survivors with undiagnosed post-traumatic stress disorder who feel forgotten or experience early ageing; people diagnosed late; refugees and asylum seekers who cannot access treatment; or people who inject drugs and are discriminated against in health services. Internationally, gross inequalities remain. There is inequitable access to treatment across Europe. Indigenous people, transgender people, female sex workers, and the homeless risk being left behind. HIV positive women are forcibly sterilised in some African and Central American countries. There are children injecting drugs who need targeted harm reduction strategies. In 80 countries, laws criminalise homosexuality. Many key populations are hard to find, hard to count and harms against them hard to measure. We know these inequalities drive the epidemic.

As nurses we must: 1. Organise, take a stand and speak out so there is no-one left behind. Nurses often identify and work with at-risk populations, but can get trapped at the coalface with little prospect of influencing sustainable change. We need to claim our place at the table in policy-making, education, and national and global HIV strategy. I hope the new relationships established between our organisations at the 20th International AIDS Conference in Melbourne can help us achieve great things. 2. Promote an enabling environment, and be serious about empowerment. We need partnerships with affected communities and international collaboration. 3. Keep raising the bar in healthcare ethics. Be persistent, stand firm with integrity and advocate for what we know works, including affirmative action for vulnerable populations, instead of ‘cookie cutter’ services that at-risk groups are supposed to fit into so they are ‘less of a nuisance’ (Rappaport, 1981).

including cardiovascular disease, diabetes, osteoporosis, liver and kidney disease, mental health problems, cognitive impairment, drug and alcohol problems. Cardiovascular disease can be related to untreated HIV infection and certain antiretroviral therapies. Premature ageing, caused by the disease, the anti-viral drugs or by a combination of both, will see more people requiring increased community and residential or high-level care. The Royal District Nursing Service (RDNS) HIV team plays a key role in engaging and caring for the most vulnerable, marginalised and disadvantaged PLHIV in Victoria. The team comprises three Clinical Nurse Consultants working across Melbourne and the Mornington Peninsula. The RDNS program is integrated with Victorian AIDS Council services to provide 24–hour care. Many, if not most, RDNS HIV clients live without the support of family and friends. There are also high rates of HIV amongst the homeless. Source: Crock. E (2013) The Royal District Nursing Service HIV Program in a changing epidemic: an action evaluation Final Report , Melbourne, RDNS.

4. Retain our sense of urgency about this epidemic. While we have hope and treatment now, we need this sense of urgency to create change and ensure that no-one is left behind. This article is based on Dr Liz Crock’s presentation to the Nurses Welcome Reception at the 20th International AIDS Conference in Melbourne, July 2014.

References Bowtell, W. (2005) Australia’s response to HIV/ AIDS 1982-2005. Report prepared for Research and Dialogue Project on Regional Responses to the Spread of HIV/AIDS in East Asia organized by the Japan Center for International Exchange and the Friends of the Global Fund to fight AIDS, Tuberculosis and Malaria (Japan). Sydney: The Lowy Institute for International Policy. Crock. E (2013). The Royal District Nursing Service HIV Program in a changing epidemic: an action evaluation Final report. Melbourne, RDNS. Mann, J. (1999). The Transformative Potential of the HIV/AIDS Pandemic. Reproductive Health Matters, 7(14), 164–172. Reamer, F. (Ed.), (1991a). AIDS and Ethics. New York: Columbia University Press. Rappaport, Julian (1981). In Praise of Paradox: A Social Policy of Empowerment Over Prevention American Journal of Community Psychology, 9:1 (Feb.) , pp. 1-25.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Spiritual Health Victoria

Spiritual Health Victoria, formerly the Healthcare Chaplaincy Council of Victoria, has launched a Spirituality in Aged Care professional development program. Spiritual Health Victoria CEO Cheryl Holmes reminded those at the launch that “getting old is not for the faint-hearted”. “Ageing can be a time of profound spiritual reflection, as people seek to find meaning in their lives and look for a continuing sense of hope and purpose,” she said.

Finding hope and purpose with age cultural and religious diversity among its members and in the community. Its professional development program was designed over three years in consultation with aged care interest groups and practitioners. The program was extensively piloted across residential and communitybased aged care facilities in regional and metropolitan settings.

“Residents of aged care facilities are often reliant on staff and volunteers to recognise their need for spiritual conversation and to ensure that it is met.”

“This is an innovative education resource designed to assist aged care providers to better understand what is meant by spirituality and spiritual care, and to identify and respond to the spiritual needs of ageing residents and clients as part of their everyday practice,” Ms Holmes said.

Spiritual Health Victoria aims to enable the provision of spiritual care as an integral part of healthcare delivery in Victoria. The organisation’s new name reflects increasing

David Stout lost contact with his faith community after moving into residential care at Hedley Sutton Community in Camberwell. At the launch of the

David Stout with Spiritual Health Victoria CEO Cheryl Holmes.

professional development program, David explained the importance of having his spiritual needs met within the place that had become his home. Further information: spiritualhealthvictoria.org.au/agedcare

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The Grattan Institute

Dying is highly institutionalised in Australia and the death that most people want often bears little resemblance to the death they, their families and carers actually experience. Although 70 per cent of people say they would prefer to die at home with family, friends and appropriate support, 86 per cent of Australians die in hospital or residential care. Many hospital deaths are lingering, impersonal and disempowered. They are also very costly. Analysis suggests that 8–10 per cent of end-of-life hospital costs are associated with the final 12 months of life, and particularly the last 30 days before death. A new Grattan Institute report titled Dying Well argues that Australians avoid discussing death and end-of-life care. A recent Grattan policy pitch event at the State Library of Victoria explored ways to improve the quality of dying in Australia. Speakers included visiting Grattan Institute Health Program Fellow, Professor Hal Swerissen. “We have a healthcare system which is focused on cure and prevention and treatment, rather than on dealing with the inevitable end of life,” Professor Swerissen said. “So very few people have their preferences and plans known in advance and, although we have well-developed systems for thinking about these things, relatively few people actually have plans for end-of-life well worked out. “There really needs to be a public debate about these issues which promotes people having discussion about their preferences for how end-of-life should occur, and that debate needs to be promoted by government systematically. “We’ve done it in a number of other areas – organ donation, campaigns to prevent people from driving badly – and dying is a critical issue to have that sort of a debate about.”

Why we need debate on death and dying The pervasive silence on this issue will become more problematic as our population ages. About 150,000 Australians die each year and with baby boomers now reaching old age, this number is set to double over the next 25 years.

Policy makers and the health sector must

A logical, systemic pathway is needed for people to discuss end-of-life care, including symptom relief and pain management, and to exercise more choice over where, when and with whom they die.

effective, universal and ethical system for

The Grattan Institute policy pitch proposed three ways to achieve this:

to have the dignified death they deserve.

1. Encouraging Public Discussion Death and dying in Australia is hidden and the topic avoided. An educational campaign is needed to encourage society, communities and policy makers to engage in a realistic conversation about the limits of healthcare, the inevitability of death, and the promotion of end-of-life care options. 2. End of Life Planning Systemic triggers and incentives are needed to encourage people to make their preferences known through advanced care planning and advanced care directives. For example, health professionals could be required to discuss end-of-life planning at health checks for people aged over 75, at entry points to community or residential aged care, at discharge from hospital, and in chronic disease management plans.

End-of-life planning in Australia suffers from duplication, fragmentation and jurisdictional barriers. A more integrated approach is needed as people move across the care continuum, for example from aged care to hospital.

3. Supporting people to die at home Many people who want to die at home will need assistance to do so in a comfortable and dignified way. This will require a substantial increase in personal care and support, medication and nursing for symptom management, psychological support, service coordination, respite care, spiritual support, counselling and advice.

take seriously the need to respect individual choices and to address the medicalisation and institutionalisation of death and dying. Open discussion is needed to develop an end-of-life planning, and to increase the provision of home-based palliative care. These steps would take Australia closer to allowing as many people as possible

The Grattan Institute report Dying Well is available

at grattan.edu.au/report/dying-well

DECISION ASSIST Decision Assist is a national palliative care service, providing advice to general practitioners and aged care staff advice on advance care planning and advance care directives. It is the collective name for the Specialist Palliative Care and Advance Care Planning Advisory Services. This consortium of seven healthcare organisations and research institutes was established with $14.8 million from the Commonwealth’s Living Longer Living Better reform package. “We know that quality end-of-life care meets the person’s needs and upholds their preferences,” Director of the Austin Hospital ‘s Respecting Patient Choices Bill Silvester said. “It is vital that all health professionals are trained in advance care planning and that we offer older Australians the opportunity to take control of decisions affecting their care.” Decision Assist provides education and training workshops, a website and a 24/7 advanced care planning telephone line. Further information: decisionassist.org.au or telephone 1300 668 908

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Balmoral Bush Nursing Centre

Balmoral Bush Nursing Centre provides clinical nursing, allied health and community services, respite and disability services to a small community of 300 people living west of the Grampians. Like other rural health services, Balmoral BNC finds it challenging to attract people with financial, legal and corporate governance skills to participate on its board. In response to this challenge, Balmoral BNC has found new avenues for recruiting board members who live outside the local community, using technology to facilitate their participation in board meetings. Balmoral BNC presented to an audience of about 1000 Australian Institute of Company Directors (AICD) members two years ago, at an event aimed at matching new AICD graduates with not-for-profit organisations.

Remote director brings new skills to bush board “Our board members have traditionally been local residents,” Executive Administration Officer Sabrina Watt says. “As governance has evolved, we have found the need to seek specialised credentials to enhance our bush nursing board. The candidate we chose had strong financial skills and a real empathy for rural Victoria.” The successful candidate, Dan Pekin, is General Manager of furniture company HTL International and a board member of notfor-profit community-based organisation, Camcare. Mr Pekin is also a certified practising accountant with formal qualifications in business and corporate governance. He lived in the Balmoral area until he was 18 and still has family there. Mr Pekin’s work is mostly Singapore-based, so he participates in board and sub-committee meetings at Balmoral BNC via Skype.

“I normally travel to Balmoral to attend the AGM and the Christmas party, so I maintain a personal connection, but using Skype enables me to participate in meetings throughout the year, regardless of where I am,” he says. Mr Pekin believes that living outside the community enables him to “ask the difficult questions” and his objectivity is valued by other board members. “I think one of the valuable skills I bring is corporate governance. The discipline and approach of corporate governance reduces potential risks for Balmoral Bush Nursing Centre.” Most importantly, this arrangement works for everyone involved. “His professionalism propels our board members to hone their governance and perhaps set the standard a little higher,” Ms Watt says.

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10 The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Victorian Healthcare Association

VHA Annual Award Winners 2014 medical staff. Nurse-led pre-chemotherapy education is a key element of the program, so that patients are familiar with the new clinic and its processes. Patients, carers, general practitioners, community services and other health services all refer patients to SURC. In the first nine months, 439 patients were treated and 942 episodes of care provided at SURC –averaging more than 100 episodes per month. A review at six months showed:

Western Health Medical Oncologist Sally Greenberg with VHA Chair Anthony Graham (left), Victorian Health Minister David Davis and First State Super representative Michael Keyte.

VHA Annual Award Western Health Symptom Urgent Review Clinic Chemotherapy commonly results in a range of symptoms due to the underlying disease or the adverse effects of treatment. Western Health patients and carers had expressed a lack of confidence in managing these symptoms. Many chemotherapy patients were presenting to the emergency department, their general practitioners or the chemotherapy day unit unwell with chemotherapy toxicities.

This resulted in delays in planned patient activity in the chemotherapy day unit, and some patients being managed in less optimal environments compared to an area with cancer specialists. Western Health established the Symptom Urgent Review Clinic (SURC) in August 2013. This alternative model of chemotherapy care provides a dedicated clinic to manage oncology patients experiencing chemotherapy-related symptoms. SURC is located within the chemotherapy day unit, staffed by experienced oncology nurses who are supported by oncology

•

a nine per cent drop reduction in chemotherapy day unit patients presenting for ED care

•

a 10 per cent reduction in patients admitted for 24 hours or less

•

75 per cent of patients being confident in their symptom management

•

75 per cent of patients saying they would have attended the ED had SURC not existed

The introduction of SURC has resulted in improved patient confidence in managing chemotherapy symptoms, clinician satisfaction with care, and a significant reduction in the proportion of chemotherapy patients attending the ED. As a result of its success, SURC is now a permanent clinic at Western Health.

VHA Members’ Choice Award Rural Northwest Health Rural Northwest Health won the 2014 Members’ Choice Award as voted by conference delegates, for its Improving the Health of Communities through Participation project. RNH staff initiated the project after hearing Professor Jane Farmer, of La Trobe University Bendigo, present at a VHA conference four years ago. Now partners in the project, they were delighted to have won this award. From left: VHA Chair Anthony Graham, Victorian Health Minister David Davis, RNH director Janette McCabe, Professor Jane Farmer, La Trobe phD student John Aitken and community representative Wendy Hewitt, and First State Super representative Michael Keyte.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Victorian Healthcare Association

VHA Annual Award Finalists 2014 Manningham Community Health Service/ Whitehorse Community Health Service Child Health Innovation Project Manningham Community Health Service (MCHS) and Whitehorse Community Health Service (WCHS) have collaborated to design and implement the Child Health Innovations Project (CHIP). The project aim is to address significant waiting times for childrenâ&#x20AC;&#x2122;s allied health programs. The CHIP has resulted in drastically reduced waiting times to access childrenâ&#x20AC;&#x2122;s allied health services, with clients now waiting an average of four weeks before an initial screening assessment takes place. Previously, the waiting time was between 12 and 22 weeks, depending on the community health service and the allied health service type. Rather than designing and implementing a new approach to service delivery, MCHS and WCHS aligned their child health referral processes.

Manningham Community Health Service representative Maria Roubos.

This partnership allowed each community health service to remain local and accessible to their community, while giving clients access to services that would otherwise have been impossible to provide with existing staffing levels. Following the successful implementation of the program, a formal consortium has been established between MCHS, WCHS and two other community health services in the eastern metropolitan region.

Rural Northwest Health Improving the Health of Communities through Participation Rural Northwest Health (RNH) has introduced a whole-of-organisation, whole-of-community project designed to embed community participation in all facets of health service operations. RNH held 24 workshops attended by 500 community members, who discussed and identified the communityâ&#x20AC;&#x2122;s health priorities as: mental health; service access and utilisation by older people; and intergenerational health and wellbeing. Community-driven strategies were developed and implemented to address these priorities. To help drive this process, RNH partnered with La Trobe University researchers to fund a fulltime PhD student. Community members were empowered with knowledge of current service models and population health data, and given an insight into RNH budgets and how they are expended. Carolyn Barrie (left), Barbara Hallam and Jacqui Hogan discuss a community project.

With these insights, community workshops resulted in: a methamphetaminespecific event; the establishment of three community gardens to support intergenerational socialisation and health education; aged care expos in two communities; and age-friendly gymnasium equipment in community spaces to promote exercise by older people and those with a disability. The variety of financially sustainable, community-driven, low-cost ideas for improving health outcomes has enabled Rural Northwest Health to move beyond traditional service-based models of healthcare and partner with community members and service providers who have been directly involved in the design and implementation of local health initiatives.

12 The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Eastern Health Early Supported Discharge Eastern Healthâ&#x20AC;&#x2122;s Early Supported Discharge (ESD) program offers mild to moderate stroke clients the opportunity of an earlier hospital discharge to participate in intensive rehabilitation in the home and community setting. An ESD interdisciplinary team of allied health, medical and nursing staff provides intensive therapy to these clients within 24 hours of hospital discharge. The program offers clients two or three face-to-face contacts per day, five or six days per week for four weeks. After this intensive period, the ESD team supports the clientâ&#x20AC;&#x2122;s transition into standard community rehabilitation programs and other community services. Embedding the ESD service into the existing community rehabilitation program has enabled stroke clients to access additional group programs, exercise physiology and weekend services as required. Eastern Health representatives Julie Smith and Erin Wilson (centre) with VHA Chair Anthony Graham (left), Victorian Health Minister David Davis and First State Super representative Michael Keyte.

In its first year, 95 clients who were admitted to ESD received 4,388 clinical sessions in home, community or centre-based settings. Further evaluation has confirmed that ESD contributed to shorter acute hospital stays for stroke clients, while achieving statistically significant improvements in client and carer outcomes. Function, stroke severity, rating of disability and quality of life measures were improved at the time of ESD client discharge and carer stress was reduced.

Peninsula Health Clinical Response Service Peninsula Health established its Clinical Response Service (CRS) to reduce emergency department (ED) admissions from 38 residential aged care facilities in the Frankston and Mornington Peninsula region. The CRS had prevented 405 admissions by June 2014, with a projection of more than 800 admissions prevented for the 2014 calendar year. The CRS team consists of doctors, nurses and allied health specialties working in collaboration with the ED, Ambulance Victoria, GPs and residential aged care facilities to provide patient-centred care in the community. Previously, an ambulance was called and aged care residents taken to hospital if a general practitioner was not available.

Peninsula Health representative Rebecca Pang.

Aged care clients often have multiple chronic health conditions and are prone to complications arising in hospital, such nosocomial infections and deconditioning, leading to prolonged stays. The number of residential aged care facilities in the region increased by 11 per cent from 2012 to 2014, suggesting that these hospital admissions were likely to increase. CRS staff promote the service and provide education to enhance the skills and capacity of all staff involved. Weekly staff meetings review patient progress and drive ongoing improvements to the CRS service. Following discharge, the CRS team follows up with patients in their home or residential aged care facility and links them with community services.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Bendigo Health

Bendigo midwives work in Delhi slums

From left: Rob Murphy of Bendigo and Adelaide Bank, Bendigo Health’s Chief Nursing Officer Peter Faulkner, Asha Foundation’s Dr Kiran Martin, Scott Ross of Bendigo and Adelaide Bank, Bendigo Health’s Fiona Faulks and David Rosaia.

Bendigo Health has sent husband-and-wife midwives Howard Hinson and Sonia Newnham to work with pregnant women in the slums of India. They have been working in Delhi for a month with the Asha Foundation, set up 25 years ago by Indian-based paediatrician Dr Kiran Martin. This is the first visit in what is set to become an annual program, funded by Twenty20 charity cricket matches between Bendigo Health and Bendigo Bank. The Asha Foundation started in the midst of a cholera outbreak in 1988, when Dr Kiran Martin travelled to a south Delhi slum, put a borrowed table under a tree and started saving lives.

Dr Martin’s widely acclaimed slum housing model incorporates programs in health, education, women’s empowerment and financial inclusion. She has lectured at Harvard, MIT and Cambridge universities and presented to the US House of Representatives and the British House of Commons. Dr Martin visited Bendigo in September to share the success stories of the Asha Foundation, which now helps more than 400,000 people in at least 50 slum colonies of Delhi. Overcrowding and a lack of water and sanitation mean these communities are typically home to 50 per cent of the city’s diseases. The Asha Foundation has given slum communities access to equal or better health services than those in India’s more affluent suburbs. Asha’s healthcare programs result in reduced child mortality, fewer maternal deaths, better nutrition, a lower birth rate and virtual eradication of preventable diseases. Entire communities become healthier, which is a crucial factor in reducing poverty.

Sonia Newnham and Howard Hinson.

Many Asha slum areas have a health centre staffed by part-time doctors, nurses and paramedic staff. They diagnose and treat patients, perform antenatal checks and

14 The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

immunise children against preventable diseases. Mobile clinics enable slums without an Asha health centre to receive an equally high level of care. While 89 per cent of affluent women have a skilled attendant present during childbirth, only 19 per cent of poor women receive this level of care. In Asha slum communities, 98% of women give birth in a hospital or in the company of a trained midwife. The under-five mortality rate (deaths per 1,000 live births) among India’s urban poor is 112.2 , while the Delhi average is 46 and in Asha slums the rate is 28.2. As well as sharing their clinical midwifery skills, Howard and Sonia have been training women in slums to work as community health volunteers. These volunteers observe their local communities, particularly pregnant women, the elderly, children under five and tuberculosis patients. They provide first aid, treat bacterial infections, give oral rehydration and advice on nutrition. They also educate their communities about immunisation and family planning and can refer them to an Asha clinic for treatment. Further information: asha-india.org or Ashabendigo on Facebook

University of Melbourne Collaboration

Improving patient care for clinically obese pregnant women who deliver by caesarean is the focus of a new University of Melbourne-led study involving seven Victorian public hospitals. Sunshine Hospital, the Royal Women’s Hospital, Mercy Hospital for Women, Northern Hospital, Northeast Health Wangaratta, Ballarat Base Hospital and Shepparton Regional Hospital are participating in the MUM Size Study. Maternal obesity is associated with increased hospital care and affects operating room planning and resourcing. Investigator Professor David Story, Chair of Anaesthesia at the University of Melbourne, said the study’s aim was to increase understanding of the best ways to care and plan for obese women requiring caesarean section in both metropolitan and regional hospitals. “Women with increased body size are twice as likely to have a caesarean delivery. Clinical teams have to consider numerous pre-existing medical conditions, such as gestational diabetes and pre-eclampsia, which is a type of high blood pressure during pregnancy,” Professor Story said. “Respiratory function must always also be monitored in these patients. There is a need to revise health policy and

CHALLENGING RESPONSES TO FAMILY VIOLENCE

Obesity impacts hospital planning and patient care guidelines within hospital care as part of a broader trend of increasing rates of obesity among both men and women.” The study will look at the duration of caesarean section operations for 1,500 patients to monitor how this affects hospital planning and patient care. “We know that obese women have an increased risk of complications with a caesarean. The risks and challenges of the procedure increase as the severity of obesity increases,” Professor Story said. “As anaesthesia care is required during the procedure, the anaesthetist becomes an important part of the care team to ensure both mum and baby are healthy. “We are investigating if maternal obesity is associated with increased difficulty with regional anaesthesia, increased operative time, increased length of hospital stay and increased use of neonatal services,” Melissa Cain had her son Wyatt six months ago at Sunshine Hospital after initially being refused maternity care at another public hospital because of her BMI. “Right from the start, the care at Sunshine Hospital was very professional and very involved. I had previously had a child with a genetic disorder, so my care was a bit more specialised”, Ms Cain said. “My doctor approached me about the MUM size study. Given that I had been

to meet the challenges of supporting women, engaging violent men, and

Ballarat Community Health’s inaugural conference will focus on the complex effects family violence has on women, men and children.

working with couples on relationships

Challenging Responses to Family Violence will be held at Ballarat Lodge on 12-13 November. The conference theme reflects the need to challenge professional, societal and cultural views about domestic and family violence.

bodies to explore best practice models

Delegates will discuss innovative professional responses and how

workshops limited to 40 places

that involve violence. There will be opportunities for practitioners, work places and funding for prevention and support services. International keynote speakers will include Dr Allan Wade and Dr Steven Stosny, who will also host one-day on 11 and 14 November.

Melissa and her baby, Wyatt.

rejected by a different hospital because of my size, I was very interested to take part. “It was to determine the health risks for mothers and babies, depending on the mother’s weight and physical health. Until doing this study, I didn’t realise that weight was such an issue for mums having babies.” Unexpectedly, Melissa became ill with the flu in her third trimester and lost almost 30kg by the end of her pregnancy. Both she and Wyatt are now in good health.

Dr Wade, who lives on Vancouver Island, Canada, promotes socially just and effective responses for people experiencing violence and other forms of adversity. He is best known for developing response-based practice. Dr Stosny, founder of CompassionPower, has authored several books and treated more than 6,000 clients for various forms of anger, abuse, and violence. Further information and registrations: bchchallengingresponsesfv.org.au/index.php Or telephone 5338 4500

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

Central Gippsland Health Service

Clients regain skills and remain out of hospital

The Central Gippsland Health Service (CGHS) fully integrated care coordination program has provided an ideal foundation for piloting a new reablement model of care.

•

there is a strong relationship between service response and recovery

•

the delegation of therapies and programs from specialist to nonspecialist staff is valued

Reablement is a time-limited, intensive interdisciplinary care approach that focuses on the individual’s goals to learn or re-learn the skills necessary for daily living. The overall aim is to maximise long term independence and quality of life.

•

care coordination and care plans extend beyond healthcare encounters to connect with the person’s life, which fosters a sense of security and confidence

The CGHS 2012–2022 Health Plan recommended this approach in response to the Victorian Government’s Health Priorities Framework 2012–2022, the HACC Active Service Model, the Commonwealth Living Longer Living Better reform policy, HACC guidelines and the CGHS 2012–2014 HACC Workforce Redesign Project.

•

A recent Australian study provided evidence to support the costeffectiveness and efficacy of reablement/ restorative approaches to care.1 Individuals had improved function and independence, which reduced the likelihood of hospital readmission or admission to residential care, reliance on home care services and unnecessary progression to more intensive, highercost home care services. A reablement-capable organisation is based on the following principles: •

•

individuals and their representatives expect to be actively involved in their care, specifically in communicating goals, monitoring progress and self- management a functional care plan means the individual’s goals form the basis for interventions, providing a sense of security and shared decision making

•

every transition is a new experience for the individual

•

there is a trusted coordinator to facilitate continuity across the organisation

disability in older people is episodic and reversible

The CGHS project aims to implement, monitor and evaluate the benefits of reablement through a targeted minipilot project, embedding the concepts of reablement across the care continuum, informed by contemporary reablement programs. The pilot involves an interdisciplinary team across acute, sub-acute, community and home care services. The study is also analysing the CGHS Care Coordination program, detailing the extent to which individuals’ goals have been identified and implemented, the timeliness of responses, care planning processes, the delegation of capabilities between various levels of staff, and clientmeasured quality of life outcomes. Participants in the study had to meet the following criteria: •

hospitalised for an acute episode of care (such as fracture, exacerbation of chronic illness or elective surgery)

•

assessed as having the potential to improve functional independence

•

willing to participate in a restorative care model with the aim of working towards functional independence

•

not having a diagnosis of dementia or a similar cognitive impairment

16 The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

The project was managed by the CGHS Community Support Officer, who also acted as the ‘client shadower’, who developed a trusting relationship with each client and their family, in order to document their experience. The project team included the CEO, Director of Community Services, senior managers, allied health, community services, consumer advocate, nursing and community carers. Two clients were identified for the first pilot and the outcomes used to improve the processes, including: •

engaging the treating Medical Officer early in the program

•

continuing to use the organisation’s Consumer Liaison Group to review and edit consumer information

•

ensuring care plans are current, shared, updated and resourced across the organisation’s boundaries

•

early identification of the client’s goals, including their connections with the community, which form the basis for the care plan

•

client participation in the care coordination process

•

engaging community care staff in care coordination, specifically the planning to transition to home

•

mentoring of community care staff to support upskilling

•

engaging the family or nominated representatives in all aspects of the care coordination program

•

having a single trusted care coordinator who helps navigate the system and sees the patient as a partner underpins the experience of continuity between clinicians

Reference 1. http://www.gha2.net.au/site/DefaultSite/ filesystem/uploads/201306050926208816/CGHS_ HealthPlan_Part1.pdf retrieved Jan 6 2014.

INDEPENDENT AFTER HIP SURGERY AT AGE 93

training the community care workers about hip precautions observing, rather than ‘undertaking his personal care, exercises, domestic assistance and meal preparation. Within three weeks the client was independent in all daily living activities, walking unaided, tending to his personal care and shopping, and had gained new living skills he did not have before hospitalisation. Under the guidance of community care staff, he learnt how to shop for healthy ingredients and prepare quick, easy meals when previously he relied on meals being delivered to this home. “It was very enjoyable to be part of the project, everyone was great,

Community Care Coordinator Jen de Rooy with a 93-year-old client

and I am not sure how I would have got on without them,” the client says.

A 93-year-old client at high risk of

An interdisciplinary team coordinated

residential care or intensive home

care planning to support his return

care participated in the CGHS

home with minimal services.

reablement project two weeks

The transition from hospital to home

after surgery for a hip fracture.

involved an occupational therapist

He is working to identify social opportunities with his care coordinator, which may result in him joining groups and programs that he has not considered before.

The Victorian Healthcare Association Issue 2 [OCTOBER 2014] vha.org.au

2015

ACHG Annual Governance Conference 2015 Thursday 23 and Friday 24 April HILTON ON THE PARK HOTEL MELBOURNE

Conference Theme: Driving organisational excellence The role of todayâ&#x20AC;&#x2122;s health sector boards extends far beyond simply ensuring compliance and signing off the annual budget. Boards set both performance goals for their organisations and, crucially, cultural expectations. A high performing organisation needs a board that truly understands the drivers of performance in health and community care and the policy environment at national, state and local levels. The 2015 ACHG Governance Conference will explore the ways in which boards can tackle this demanding role, move their organisations beyond a focus on minimum standards and drive excellence in healthcare. A range of speakers will share their insights on the structures, processes and partnerships that drive organisational performance and will provide useful examples of innovative practice. Who should attend? Health and community sector board members, CEOs and senior managers; local and state government representatives from around Australia. Enquiries: Phone 03 9094 7777 Email achg@healthcaregovernance.org.au

2015

ACHG Governance Excellence Award 2015 Thursday 23 April

HILTON ON THE PARK HOTEL MELBOURNE

Showcasing outstanding contributions in furthering the governance of public health services. For eligibility and criteria details: Phone 03 9094 7777 Email achg@healthcaregovernance.org.au

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