Far West Local Health District’s Improve, Enhance and Supplement Chronic Obstructive Pulmonary Disease Outcomes Project

This project targets prevention in potentially preventable hospitalisations for people with chronic obstructive pulmonary disease (PPH-COPD) and strengthens an integrated care model for the management of the disease.

View a poster from the Centre for Healthcare Redesign graduation December 2021.

Aim

• Improve the patient journey for patients with COPD by avoiding preventable hospitalisations and the corresponding physical, social, and emotional effects.
• Enhance clinician experiences in delivering care and supplement efficiencies of care by transforming how Broken Hill Health Service’s medical ward delivers the right care, at the right time, with right the patient reported outcomes by 31 December 2022.

Benefits

• Reduces avoidable presentations for COPD conditions in the emergency department and subsequent hospitalisations into medical wards.
• Strengthens primary care in the better management of COPD.
• Reduces the risk of complications through an improved, more coordinated, and culturally appropriate approach to patient care.
• Improves patient’s quality of life with minimum disruption to normal routines due to avoidable hospitalisations.
• Reduces healthcare costs and prevents bed blocks.

Background

FWLHD is the most sparsely populated local health district across NSW. It has an estimated resident population of 30,144 people.¹ People of Aboriginal descent constitute 13% of the overall population, the highest proportion in NSW.^2,3 As a region, the Far West of NSW has five local government areas.^4,5 Two of the local government areas are classified as ‘remote’, while the remainder are classified as 'moderately accessible'.⁶ Four of the five local government areas have a lower socio-economic status when compared to the state average with three within the lowest Socio-Economic Indexes for Areas socio-economic quintile.^4,5,6

FWLHD is a complex and evolving health organisation, serving diverse communities with a high burden of chronic and complex care needs. People living in remote parts of Australia have higher rates of chronic disease as compared to people living in urban and regional areas.⁷ Rural and remote populations also experience relatively higher lifestyle risk factors, such as smoking and alcohol consumption, obesity, and lower physical activities.⁷

Chronic conditions are a leading cause of PPH in the FWLHD.^8,9 PPH are defined as those hospitalisations which could have been avoided with access to quality primary care and preventative care.¹⁰ High rates of PPH for certain chronic and vaccine preventable conditions could be reflective of larger issues associated with access to care and effective primary care in the region.¹⁰ FWLHD’s rate of PPH-COPD is significantly higher than the state average.⁹

COPD is a progressive and disabling health condition that limits airflow in the lungs and is a leading cause of hospitalisations and premature deaths.⁷ COPD is commonly associated with heart disease, lung cancer, stroke, pneumonia, and depression.⁷ Age, ethnicity, socio-economic determinants, comorbidities, air pollution, a person’s ability to afford care, access to healthcare services and asthma are some of the associated risk factors for COPD hospitalisations.⁷

The project is underpinned by NSW Health’s quadruple aim of 'better outcomes and improved clinician and patient experiences at lower healthcare costs'.¹¹ It also aligns FWLHD’s Priority # 1 - Enhancing Access To Evidence-Based, Quality, and Integrated Health Care, which is at the heart of the vision for this project.¹²

Implementation

Solutions

FWLHD identified the following three solutions for implementation.

Improved and innovative patient self-care packages and patient support group

FWLHD has successfully established a patient support group that have co-designed innovative patient self-care packages using multi-component knowledge dissemination strategies, that is printed, website and audio-visual. Development of the packages is underway, and they are expected to be made available by July 2022.

Expansion of the In-Home Remote Monitoring Program

The program offers ongoing monitoring and early identification of clinical exacerbations in the identified patient cohort.

We have developed a structured process to identify the targeted patient cohort (PPH-COPD) and introduce the patients to FWLHD’s Integrated COPD Care Pathway which embeds the project solutions.

The In-Home Remote Monitoring Program has been extended to include the targeted patient cohort.

The COVID-19 pandemic provided an impetus to patient uptake; however, clinicians have been engaged in the regional COVID-19 response strategy, hence capacity constraints have limited expansion opportunities.

We will focus on enrolling all the consented patients until July 2021 and then embed the enrolment as part of the usual process.

Streamlined workflows and introduction of electronic referrals

Workflows for the Chronic Care Team (Integrated Care for People with Chronic Care Conditions) have been reviewed in consultation with the team and are in process of being documented. Electronic referrals to the Chronic Care Team have been developed in the electronic medical record. They were tested successfully in July 2021 and are visible on the electronic patient journey boards. Full implementation of the workflows and electronic referrals will be part of a separate project in the 2021-22 financial year.

Status

Implementation – The project is ready for implementation or is currently being implemented, piloted, or tested.

Dates

February 2021 to December 2022.

The project implementation milestones have been impacted by the COVID-19 pandemic and reviewed milestones have been approved by the governance committee. At this stage they do not impact the project end date, but progress is being closely monitored for changes, if any.

Implementation sites

Broken Hill Health Service’s medical ward as a pilot.

Following a successful evaluation, the project will be systematically to be rolled out across FWLHD.

Partnerships

We have partnered with Western NSW Primary Health Network, NSW Ambulance, and general practices in Broken Hill for this project.

Results

We have started noticing improvements by adopting a multi-component approach to our planned solutions (prototyping and testing), beginning with identifying the targeted patient cohort that drive the numbers. Working with a specific cohort allows the FWLHD to use resources optimally to achieve desirable outcomes by working with the patients and planning their care (Integrated COPD Care Pathway) based on their needs and preferences.

We have noted a 41.6% improvement (Feb 2021 annualised 3-year average 89 episodes compared to annualised Mar-Jul 21 episodes at 52) in year-to-date PPH-COPD episodes. Some of the results have also been impacted due to deaths of two patients, who previously contributed to higher number of hospitalisations.

With the full implementation of the solutions by December 2022, we expect significant improvements in all key project deliverables, that is reduction in PPH-COPD episodes, clinician experiences in delivering care, patient reported outcomes of care and reduction in healthcare costs.

Lessons learnt

• Clinicians and patients should be actively engaged to calibrate understanding of patient journeys and then to co-design effective solutions.
• Diagnostics are critical to success. If the root causes and data sources are not accurately identified, projects will not achieve the desired outcomes.
• Focussed strategies to address behavioural aspects, or human elements of change, are key to the project success and implementation outcomes.
• The probability of success is high when there is a consensus on the evidence, context in which the evidence is being implemented and local facilitation mechanisms pertinent to patient preferences, needs and circumstances.12
• Strong partnerships with health service organisations and partner organisations can impact system-wide improvements in the region.

References

1. HealthStats NSW. Population by Age: by Local Health District and year [Internet]. Sydney: NSW Ministry of Health; 2019 [updated 2019 Mar 19, cited 2020 Mar 15]. Available from: https://www.healthstats.nsw.gov.au/Indicator/dem_pop_age/dem_pop_lhn_snap
2. HealthStats NSW. Population by Aboriginality [Internet]. Sydney: NSW Ministry of Health; 2016 [updated 2020 Feb 26, cited 2020 Mar 15]. Available from: https://www.healthstats.nsw.gov.au/Indicator/dem_pop_Aboriginality/
3. Australian Institute of Health and Welfare. Rural & remote health [Internet]. Cat. no: PHE 255. Canberra: Australian Institute of Health and Welfare; 2019 [updated 2019 Oct 22, cited 2021 Mar 15]. Available from: https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health
4. Australian Bureau of Statistics. Socio-Economic Indexes for Areas (SEIFA), 2016 [Internet]. Cat no. 2033.0.55.001. Canberra: Australian Bureau of Statistics; 2018 [cited 2019 Oct 14]. Available from: https://www.abs.gov.au/AUSSTATS/abs@.nsf/ DetailsPage/2033.0.55.0012016?OpenDocument
5. Department of Communities and Justice. Far West District Data Profile: Murrumbidgee, Far West and Western NSW. Sydney: Department of Communities and Justice; 2021. Available at: https://facs-web.squiz.cloud/__data/assets/pdf_file/0011/725843/Far-West-District-Data-Profile.pdf
6. Australian Institute of Health and Welfare. Chronic obstructive pulmonary disease (COPD) [Internet]. Cat. no. ACM 35. Canberra: Australian Institute of Health and Welfare; 2020 [updated 2020 Aug 25, cited 2020 Dec 03]. Available from: https://www.aihw.gov.au/reports/chronic-respiratory-conditions/copd
7. Far West Local Health District. ICD-10 Reports. Broken Hill: Far West Local Health District; 2020.
8. HealthStats NSW. Potentially preventable hospitalisations by condition [Internet]. Sydney: NSW Ministry of Health; 2019 [updated 2020 Mar 10, cited 2021 Mar 15]. Available from: https://www.healthstats.nsw.gov.au/Indicator/bod_acshos_cond/bod_acshos_cond_lhn
9. Australian Institute of Health and Welfare. Potentially preventable hospitalisations in Australia by age groups and small geographic areas, 2017-18 [Internet]. Canberra: Australian Institute of Health and Welfare; 2019 [updated 2019 Nov 14, cited 2021 Mar 15]. Available from: https://www.aihw.gov.au/reports/primary-health-care/potentially-preventable-hospitalisations/contents/about
10. NSW Ministry of Health. About value based healthcare [Internet]. Sydney: NSW Ministry of Health [updated 2020 Aug 14, cited 2021 Oct 18] Available from: https://www.health.nsw.gov.au/Value/Pages/about.aspx
11. Far West Local Health District. Strategic Plan 2016 - 2021. Broken Hill: Far West Local Health District; 2017. Available at: https://www.fwlhd.health.nsw.gov.au/UserFiles/files/About%20us%20(Far%20West)/
    PDF%20version%20FWLHD%20Strategic%20Plan%202017.pdf

Further reading

• NSW Agency for Clinical Innovation. In-home monitoring program for people with chronic conditions – Far West LHD. Sydney: ACI; 2021.
• Kitson AL, Rycroft-Malone J, Harvey G, et al. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci. 2008 Jan 7;3:1. DOI:10.1186/1748-5908-3-1

Contact

Rebecca Smith
Integrated Care Manager
Broken Hill Community Health Centre
Far West Local Health District
Phone: 08 8080 1507
Rebecca.smith7@health.nsw.gov.au