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Improving access to health services for vulnerable populations. Project Review and Qualitative Process Findings. 2007-2010 March 2010. Project Review :Summary of trial sites. Description of the trial. 2. Maximise value of each contact BPAC form Identification of overdue basic care.
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Improving access to health services for vulnerable populations Project Review and Qualitative Process Findings 2007-2010 March 2010
Description of the trial 2. Maximise value of each contact BPAC form Identification of overdue basic care • Target outreach • Query and PMS information use • Listed any registered patients with evidence of asthma, diabetes or ischaemic heart disease who have not been seen in the last 6 months. • Date of last recorded encounter • All Read codes for these conditions • Any prescription for • Hypoglycaemic medicines • Vasodilating nitrates • Inhaled steroids or combination inhalers 3. Cultural awareness training
Outreach activity to date • Figures to March 2010
Discussions focused on the process of delivering the service, more specifically Process and operation details Identification of events that may have affected implementation or outcomes. Next steps/improvements Qualitative Process Evaluation Interviews completed October 2009 – February 2010
Findings Stocktake, literature review and formative findings available at www.improving access.co.nz
Targeting outreach and maximising the value of each contact • Few nurses use the PMS effectively • Outreach has largely been referral led with limited checking of eligibility • Reasons • Nurse attitude towards delivering health care in the home • Home visits criteria • Employment status • Use of IT • Capacity issues
Exposure to home environments Some nurses reluctant to, or unsure about how and when, to approach health issues Confronted with socioeconomic problems Involvement is time consuming Not necessarily qualified to deal with the issues Transition to health care Not smooth Not always possible Uncertainty about when to approach health issues Embroiled in some situations Provider, rather than facilitator of access to, services Struggle to replace themselves in the service equation “ You have to prove yourself when you get in there – Show that you are going to help. Sort out their benefits so that they can pay for care. You can’t plough in there asking to take their blood pressure – Not right away!’ Nurses attitude towards offering health care in the home
Where Home visit criteria exists • Criteria varied across the sites • Commonly included recall checks • Related to underlying contract requirements • Typically included one or more of the following: • Did not attend secondary care appointment (list provided by the hospital) • Recently discharged from hospital (Electronic discharge summary sent to PMS) • Avoidable hospital admission (List provided by the DHB) • Overdue screen, immunisation, diabetes follow up (queries run in the PMS) • No CVD risk assessment recorded (PHO generated list) • Palliative care (referral from a practitioner) • CCM programme (List of those eligible from PHO)
Run PMS queries Start Run PMS queries Generate a list of potential outreach recipients Generate a list of potential outreach recipients Assess the list through PMS record check and use of professional’s knowledge about the family Assess the list through PMS record check and use of professional’s knowledge about the family Receive referrals Start Receive referrals Confirm reason for outreach activity or home visit Confirm reason for outreach activity or home visit No No Yes Yes Complete recall. In the event of no response Complete recall. In the event of no response Adjust PMS record accordingly (e.g. correct coding) Adjust PMS record accordingly (e.g. correct coding) Complete outreach activity Complete outreach activity Code outreach in the PMS and complete PMS record results in End : Code outreach in the PMS and complete PMS record Referral Based Nursing Outreach Some referrals will not meet the trial eligibility criteria For example: Those seen at the clinic and referred for follow up
PHO employed Protected time to deliver the service Work across a number of practices Estimate 1FTE can work across 10-14 GPs or patient population of 20-30,000 Require help to judge eligibility More likely to accept all referrals at face value Takes time for referees to understand the service Practice employed More likely to be prohibited from outreaching by other duties Have the trust of the practice Know the patients so can judge eligibility Employment status
Use of IT In addition to good PMS record keeping. The trial required outreach nurses to: Use best practice reports to identify / address overdue aspects of care Use PMS to identify those eligible for outreach Code all outreach activity
Use of IT: Findings PMS record keeping. Some clinical information is incorrectly entered as free text Some referrals are not recorded in the PMS Some nurses use external software to provide outreach reports Use best practice reports to identify / address overdue aspects of care 1 in 3 did not use the report facility Use PMS to identify Queries abandoned Many referrals accepted at face value with little interrogation of PMS Code all outreach Activity 1 in 5 did not correctly code Reasons: Varied understanding, no adoption of new practice , preferences for more traditional practice/referrals based service
Large variation in number of calls, visits and other activities accomplished by 1 FTE per week Predominantly associated with underlying contract and employment arrangements “I complete 4-5 visits in two and a half days”[PHO employed working across 2 practices with limited management support and no activity requirements specified in the service contract] “We have done about 30 visits in the last couple of months – To be honest I have been busy with other things. We are one practice nurse down and we are just trying to fit this in when we can.” [Practice nurses with no activity requirements specified in the service contract] “About 4-5 visits a day –most weeks it would be 20-30. Our PHO contract requires that number of visits – I have to follow up all DNAs and all those who don’t have a CVD risk measurement and now immunisations and screening.” [Practice employed, number of outreach visits required specified in the service contract ] Capacity
Resource use Reengagement with health services often depends on Actions of other services Nurses address of socioeconomic issues Struggle to navigate and secure help Exposes gaps in and problems gaining access to other services Who should fund? Can the health budget sustain use of its resource to address socioeconomic problems? Service delivery
Local service directories • Did not exist in some areas • Nurses assimilated their own information • Time taken and process used variable • End result was sometimes an informal directory that could not be used by others
Other events affecting the services Capacity issue Resulting in increased demand to address socioecon problems Preventing travel in some areas
Content of the three sessions did not : Take into account existing cultural accreditation, knowledge or practice Meet attendees’ expectations Advance existing knowledge or practice Delivery of the 3 sessions was criticized on the basis of: Facilitator skill and experience level Expectation that the course would be delivered by a recognized cultural expert Time involved for practices in relation to outcome from session attendance Delivery style not conducive with group interaction, and perception that it could be effectively delivered by distance learning Feedback on cultural awareness training
