Background
Methods
Partnership models of care
Focus groups evaluating models of care (MOC)
Results
Quality improvement processes
Barriers identified in 2012 | Activities and impact of NT DIP Partnership |
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Communication
Breakdown between tertiary and primary health services referral pathway difficult, unsuitable specialist clinic times
| - Workshops and regional meetings resulted in an increased understanding of roles and priorities of different disciplines from tertiary and primary health care settings and increased contact between clinicians; created congenial relationships and enhanced case conferencing and discussion. - Engagement of clinicians in process of development of referral pathways resulted in an increased uptake of referral pathways and care plans. |
Access
Lack of access for remote clients to specialist services (e.g. dietitians), food insecurity
| - Increased access to specialist services through telehealth and allied health outreach visits resulted in enhanced local health professionals’ knowledge. - Establishment of nutrition in pregnancy working group resulted in the development of nutrition education resources. - Partnership activities resulted in midwives taking on the role of commencing blood glucose monitoring with the women. All NT diabetes services are now able to provide home blood glucose monitoring equipment to women. Women are now more likely to have blood glucose profiles when attending appointments. Prior to this, women presenting for the first time at the antenatal clinic with a diabetes diagnosis, rarely came with a glucose monitoring profile. |
Education
Health professionals reported knowledge gaps, no structured education available, resources for women not easily located
| - Partnership staff delivered workshops, education sessions and presentations at hospital for a grand rounds, Primary Health Network events, university undergraduates and conferences across the NT, facilitated by primary health and tertiary organisations. - On-line learning modules were developed for health professionals. - Investigators revised local guidelines to be in line with ADIPS and WHO, and incorporated them into Central Australian Rural Practitioners Association (CARPA) Standard Treatment Manual (6th Edition) and the Minymaku Kutju Tjukurpa – Women’s Business Manual (5th Edition). - Educational activities have heightened awareness of early detection of DIP leading to the development of a clinic in one Aboriginal Medical Health Service for women to attend to have an OGTT (either antenatal or post-partum). - Educational activities have resulted in an increased awareness of testing and reporting of DIP, with annual increases in numbers of women with DIP being reported by NT Midwives Data Collection. |
Coordination and Transition of Care
Unsure of who was involved in management of women and who was responsible for co-ordinating the care. between primary and tertiary health services.
| - Patient Journey Modelling and educational partnership activities resulted in increased clinician contact which enhanced the coordination and transition of care. - Workshops and regional meetings resulted in specialist clinic time revised in order to suit assessment and treatment modalities with minimal ‘out of community’ time for the women. - Workshops and regional meetings resulted in care-coordination becoming part of clinical care at outpatient clinics with a meeting at the end of each clinic for multi-disciplinary team members to collaborate on a plan of care for complex cases. - Electronic care plans for diabetes in pregnancy were developed for use in primary health care. - The clinical register generates a weekly working list for monitoring the care coordination of women with diabetes in pregnancy at each hospital in the NT. |
Baseline (2012) | Current (2016) |
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Communication | |
Centralised specialist clinics in tertiary hospital
Poor communication between services (with opportunities to improve use of telemedicine) | - Systemic integration of telemedicine into health services - Regular case conferencing with remote clinics through telehealth - Clinical Register reports circulated quarterly with information around prevalence of DIP across regions - Improved referral pathways - Enhanced awareness by PHC clinicians of availability of hospital-based specialists for phone advice and case conferences |
Access | |
Limited engagement of diabetes and allied health specialists in remote settings and limited access to these specialist services close to home for remote women
| - Regular outreach visits and telehealth by specialists (including dieticians) - Increased capacity of Primary Health Care clinicians to manage DIP in remote communities with support by phone/telehealth from hospital-specialists (hub and spoke model) |
Education | |
Minimal DIP educational activities for Health Professionals
Limited self-management educational resources available for women
Limited access to glucose monitors
| - Regular DIP educational forums for Health Professionals (including a focus on preconception care and postpartum care) - DIP educational resource for women - Free access to glucose monitors |
Coordination and Transition of Care | |
Remote clients required to travel to access specialist care
| - Specialist clinic times changed to better meet the needs of remote clients - Electronic care plans used in primary health care. - Multi-disciplinary collaboration at outreach meetings to coordinate care provided to complex cases |
Clinical Guidelines | |
Use of a standard treatment manual, based on the Australian Diabetes in Pregnancy Society guidelines
Different guidelines used in Primary Health Care and hospital and in different regions within the NT
| -Adoption of International Association of Diabetes in Pregnancy Study Groups and World Health Organisation guidelines (which have a lower threshold for diagnosis and earlier screening) -Guidelines were aligned between Primary Health Care and hospital to be consistent between guidelines and across all NT regions -Strong promotion of guidelines in education sessions |
Orientation and guidelines
|
‘There’s so much expert knowledge that we have developed in the NT, most people actually don’t know when they first arrive.’(Public Health Physician)
‘There has been involvement from the remote nutritionists […] more access to dieticians [resulting in] a real robustness around the remote midwives feeling comfortable about some basic messages.’ (Diabetes educator) |
Education
|
‘[We] are dealing with a population with the most complex health issues […] the most complex social issues. Of course, it is not going to be easy.’ (Public health physician)
‘[There is] so much more awareness out in the community now’.(Diabetes educator) |
Communication
|
‘The trouble with midwifery coverage in Central Australia is that it is delivered by five different services all accountable to different line managers, all with different priorities and stuff like that. And no sort of overall clinical coordination.’ (Remote midwife) |
Logistics and Access
|
‘[Continuity of care is made] easier because [of] the [Aboriginal] Liaison Officer who […] actually go[es] out to some of the hostels in Alice Springs and bring[s] [clients] in.’ (Remote diabetes educator) ‘[Aboriginal Health Practitioners are critical especially] if we don’t know where people are staying, or we don’t know if they are in [town], we do not have a clue how to get a hold of them to bring them in[to the clinic].’ (Remote diabetes educator)
‘[Since the commencement of the partnership] there’s been a really strong level of engagement which has been a very positive thing because it takes a few years of you know people getting new information and then looking at how they integrate that into their routine work practice and you know I suspect it may not be until actually after the end of the project that we really start to see perhaps the impact of what’s all the changes that [….] been putting into place.’ (Diabetes Educator) |
Information Technology
|
'A dedicated virtual clinic [like] tele-health [would overcome some problems with communication]. (Diabetes educator) |
Opportunities for further improvements in MOC
|
‘[A Care Co-ordinator would be useful] because you’ve got such a vast area of clinics with you know, who don’t have the resources of the midwife or people who know what they’re doing, I think that’s a great idea.’ (Remote outreach midwife) ‘A health directory would be very very useful.’(Remote general practitioner) ‘We need a mechanism to take collective knowledge, so that when someone comes in new, [they don’t] have to wait until they’ve been here for seven years before they know who to refer to.’ (Public health physician) |
Orientation and guidelines
We tend to stay ahead of the game because of the population prevalence and so we move to things faster than we would in a general population.
Education
Communication
As expressed by a diabetes educator, it has facilitated health professionals ‘…understanding each other’s business better’, and improved ‘collaboration between the midwife and the diabetes educator’. As a quality assurance tool, the establishment of the clinical register has also had positive implications for improved communication between relevant stakeholders.…the regional meetings, the clinical reference group and […] one of the really important things there is the multi-disciplinary nature which […] has broken down those silos and given people permission to be talking on a more regular basis. In terms of staff morale, just thinking across everyone, staff morale actually seems very high with this […] Partnership.
This is further implicated by health professionals often not knowing who to contact. Remote area nurses were quoted by a remote outreach midwife as saying ‘“who do I ring? […] I don’t know what to do”’, and then ‘they ring the remote medical practitioner who is their program doctor, and that person is in Sydney (major city 3,934km from Darwin) and they’re not sure either.’I find that the most tedious part of the practice – is actually communicating with all sectors these women are involved in.
Logistics and access
Information technology
‘we get regularly rung up by people who haven’t checked e-health so the staff turnover here with people not knowing or getting orientated on to e-health or not hav[ing] access is just so huge.’
Recommendations for improved care-coordination
In addition, data supported the need for clearly outlining who to call for advice in various regions, particularly important in the context of high staff turnover in remote clinics.[In] Central Australia when [the Aboriginal women] come into town, they just get lost. There’s no-one co-ordinating their care in town.