An Alternative Model of Care

Dr Anna RantaConsultant Neurologist MCDHBAssociate Dean University of Otago

The Waitlist Problem

Dr Anna RantaConsultant Neurologist MCDHBAssociate Dean University of Otago

Overview

Background Improvement Strategies

Nested within Secondary Care Nested at Primary/Secondary Interface

Show casing Non-Contact Specialist Assessments

Lessons Learned and the Way Forward

Why did we bother?

Born out of necessity 2 year wait lists Some patients never seen Non-transparent prioritisation Poor follow up and high DNA rates Poor Team Morale Clinician versus Manager

What did we do?

Consider, understand, and own the problem as a TEAM: Numbers on wait list by priorityNumbers seen each monthNumbers referred each month

Deal with backlog to stop drowning Determine and increase capacity Consider ‘Alternative Models’

Solutions: Secondary Care

Delegate/empower team members:Neuro RN phone/email adviceTechnician education and reportingNurse education and clinicsMDTs

Close relationship with manager to write business cases and manage budgets

Solutions: Primary Care

GP Education and Engagement Teaching (peer review) Guidelines, publications, and audits Clinic letters, emails, phone advice

GP empowered w/ specialist back-up Access to diagnostics (e.g. CT headache) Electronic decision support (e.g.TIA) Limiting follow-up (Non-contact Clinics)

When capacity is reached: Non-contact clinics Aka ‘Virtual’ Clinics’ (FSA and FU) Origins in reluctance to ‘simply turn

patients away’ Not an alternative to face-to-face

assessments, but as an alternative to NO assessments

Tracked, counted, and now funded

What does it entail?

Referrer writes to specialist Patients who are anticipated to

(a) likely wait more than 6 months (b) have simple problems better served

with quick written response (c) needing primarily an investigation

Triaged into “NC-FSA”

Then what?

Prior specialist letters and other relevant documentation/diagnostics reviewed

Some additional diagnostics accessed through secondary care

Management plan created to be implemented in primary care

Formal letter written to GP/referrer w/ option to re-refer

What is the cost?

Face-to-face = 45 min NC-FSA = 15 min Funded at 1/3 regular FSA Now offering NC-FU (not funded) Other similar activities not funded:

RN calls/emails and educationStaff education ‘Curb side’ consults

NC-FSA Audit Data July 2008 – August 2009

Adverse events

3 (1.35%) delays in dx1 (0.45%) detriment

no permanent disability

Referral Details (n=222)

GP Feedback (n=47)

Q1 Did you find the advice helpful in terms of probable diagnosis, management, or simple reassurance?Q2 Did you share the specialist opinion from "non-contact assessments" (virtual clinics) with the patients?Q3 Did you have difficulty when the neurologist said the patient couldn't be seen but advice was provided in writing?Q4 Do you think treating patients via specialist written advice when they cannot be seen within 6 months improves patient care?Q5 If a patient cannot be seen by the neurologist because of lack of resources, would you rather have the referral returned without advice?Q6 Would you rather patients wait longer than 6 months but eventually see the neurologist?

131 surveys sent out, 47 replies received, where % do not add to 100% remainder did not answer question

Overall Benefits

All patients referred receive a specialist opinion

Wait times improved (>2yrs3-6months) Better primary/secondary interface

Empowered yet supported GPs More inter-collegial trust Up-skilled GPs

Care closer to home for patient and often achieved faster

Lessons Learned

Emphasise: Not instead of face-to-face, but instead of no care

Born out of necessity and not a panacea, but a unexpected positives

Specialist the hardest to convince Patient/referrer expectations need to

be managed, but minor hurdle

The Price of Increased Efficiency Traditional model of ‘letting wait list

grow’ alive and well Blame management; need more $ Inequities across services Specialist Training at risk Specialist Existence at risk? Specialist Burn-out?

The ‘Alternative’ Model

Rethinking Specialists role: Shift some specialist resource away

from face-to-face patient contact More emphasis on:

Education, supervision, and support Team approach (within/across sectors) Population Health & Clinical Leadership

Ideally Hospital/DHB/region wide with less focus on our own specialties

Next Steps

Efficiency to be promoted through appropriate rewards/incentives

Funding stream adaptation to properly recognise/fund ‘non-contact’ time

More clinician engagement to ensure safety: work with not against management

Public perception to be further shaped to understand and accept limitations

Strive for good and equitable care across specialties, sectors, and DHBs

Summary

YES, there is a resource problem And NO it is not going to go away BUT in NZ we are well ahead of the game A bit of ‘can do’ attitude goes a long way ‘Can do’ teams with ‘can do’ leaders and

‘can do’ managers even better…. In my mind the goal is to achieve

comprehensive, conscientious, and equitable health care to our entire population

QUESTIONS?