Finley Medical Centre serves a large catchment area on the New South Wales-Victoria border, including the towns of Finley, Berrigan, Tocumwal, Jerilderie, Deniliquin, Barooga and Cobram.
The practice employs four general practitioners and three practice nurses. It supports more than 4000 patients from newborns to the elderly, and including 211 respiratory patients. The practice began collecting patient reported measures (PRMs) via the Health Outcomes and Patient Experience (HOPE) platform in June 2023. The PRMs managers at Murrumbidgee Local Health District (MLHD) provided training and education sessions, workflow mapping and ongoing support.
The practice initially collected the following patient reported outcome measures (PROMs):
- COPD Assessment Test
- EQ-5D-5L (Generic Quality of Life)
- Falls Efficacy Scale International (FES-I).
Clinician feedback has been positive, with PROMs offering:
- a deeper insight into patients' symptoms and function
- the opportunity for patient education with practice nurses
- a way to quantify patient self-reported outcomes, identifying the need for changes to care prior to the patient seeing their treating GP.
With support from Murrumbidgee Primary Health Network (MPHN) and MLHD, Finley Medical Centre extended its PRMs cohort in February 2024 to include other respiratory patients, particularly asthma patients, using the St George Respiratory Questionnaire. This aligned with the local Collaborative Commissioning initiative Living Well, Your Way, further reinforcing the value of PRMs connecting care across the care continuum. Collaborative Commissioning is a partnership between LHDs and other service providers to improve health outcomes for people living with chronic disease and address community health needs.
Patient-reported measures workflow
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Respiratory nurse, practice nurse or GP identify COPD or other respiratory patients and advise administration staff.
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Administration staff search for patient in HOPE on patient list, register new patient to HOPE location and assign clinical program (COPD and other).
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When patient arrives at the practice, the nurse introduces PRMs and HOPE, and obtains consent from patient. Patient or carer completes PROMs in clinic during the consultation with nurse using iPad or PC.
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Practice or respiratory nurse discusses results, recommends interventions and referral options with patient.
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Practice or respiratory nurse also contacts the relevant treating GP and initiates any referrals discussed with patient, including documenting individual goal setting for patient to take home.
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Patient notes are recorded in Medical Director (general practice management software), including saving any PROMs results as a PDF into patients Medical Director file.
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Patient list is regularly reviewed to identify any unread or unactioned PRMs.
Clinician story
Engaging in the PRMs surveys with patients helps us to elaborate on areas of concern, and to determine if there are other methods of treatment or resources that will help patients to improve their chronic disease and or quality of life. These opportunities may not otherwise arise, and patients have been welcoming of the opportunity to answer the questions.
I am currently completing three monthly reviews and second assessments, which the patients are finding very useful. It gives them a clear idea around their progress and where things can be improved.
Benefits of patient-reported measures
Benefits for the patient
- PRMs help to identify where there is a need for patient education, in particular the use of asthma relievers and preventative inhalers for respiratory patients.
- Results guide goal-setting conversations and help demonstrate a patient’s progress with management of symptoms.
Benefits for the service
- PRMs facilitate more in-depth consultations with patients who have COPD and other respiratory illnesses. Clinicians are able to elaborate with patients around their chronic illness, their disease management and what can be improved.
- PRMs assist with identifying education needs of individual patients and supports evaluation of practice model.
Benefits for the organisation
- PRMs provide a unique opportunity to extend the collection of data for COPD across the continuum of care. This was achieved by aligning the current Collaborative Commissioning initiative in MLHD and the MPHN Winter & Summer Strategy initiatives, targeting COPD and respiratory patient cohorts in general practice and external primary care providers e.g. physiotherapist and exercise pysiologists.
- Long-term alignment with LHD and PHN Collaborative Commissioning initiatives enables the expansion of PRMs to include additional patient cohorts at participating practices, and the potential scale-up to other GP practices in the future.
Helpful tips for other services
Collaboration with PHN as a sponsor and connector to the GP Practice. Leverage off existing relationships, initiatives, funding opportunities and reporting requirements. Dedicated practice nurses time to collect PROMs and discuss results with patients to support provision of individualised care.
Locally led and delivered by LHD PRM managers who have had experience with implementation, support and education locally. Knowing the local ways of working, networks and resources available is an underestimated asset.
No one approach is the same as the last, be flexible. GPs appreciate contact face to face not just virtually. Integrate PRMs into specific care models and highlight broader applications, such as Medicare health assessments for older patients, to increase buy-in from GPs and practice managers.
Clinical engagement approach
The NSW Primary Health Network (PHN) CEO group endorsed trialling a joint approach to PRMs collection with NSW Health. The aim was to understand how to adapt requirements for primary care in change and adoption, and data governance and management. The expression of interest process was facilitated by the Agency for Clinical Innovation (ACI) for PHN trial sites – Murrumbidgee was one of three successful networks.
MPHN and MLHD included PRMs and HOPE in the Collaborative Commissioning initiative – Living Well, Your Way (LWYW) COPD Cohort. The approach included:
- an expression of interest process facilitated by MPHN with local general practices
- locally led implementation approach with MPHN and MLHD
- PRMs team
- five practices onboarded as of June 2024, including Finley Medical Centre.
Onboarding was modelled on the current MLHD implementation process. It was locally led, implemented and supported by MLHD PRMs managers with ongoing collaboration with MLHD Collaborative Commissioning, MPHN and ACI PRM Primary Care:
- MLHD PRMs managers co-ordinated HOPE onboarding, training and implementation activities directly with practice staff, including establishing local workflows and providing onsite go-live and ongoing support.
- Additional resources and onboarding support were provided by the ACI PRMs Primary Care team.
- MPHN led the implementation of the Collaborative Commissioning initiative, overseeing management of the EOI process and local contract management.
- Regular planning meetings are attended by MPHN, MLHD and ACI Primary Care teams to discuss any local or statewide considerations for service planning and implementation.
- Barriers included time restrictions in the general practice environment with 15-minute appointments scheduled for patients presenting with complex health needs. There is limited time for additional patient education, with no associated Medicare item numbers, making it challenging to embed patient education in clinical workflows.
- Another barrier is the absence of local asthma educators or pulmonary rehabilitation services requiring patients to travel.
Organisational structure
Local sponsor: The Finley Medical Centre Practice Principal volunteered for the practice to be part of the program and played a key role in advocating for the use of PRMs at the service level, promoting on-going PRMs use as part of business-as-usual activities.
Regional sponsor: The MLHD Authorising Sponsor for the PRMs program and Director of Clinical Governance. This role is crucial for advocating for PRMs at the organisational level, supporting continuous implementation, expansion, and dissemination of PRMs and addressing barriers at a local level. The Authorising Sponsor for the PRMs program at MPHN level and manages the Primary Care Engagement teams and leads broader engagement with other relevant PHN teams.
This role is important for driving PRMs adoption at a PHN level and identifying opportunities to partner with engaged local general practices to embed PRMs into service delivery models and quality improvement initiatives. The role is a reinforcing sponsor across MLHD and MPHN supporting the inclusion of PRMs into Collaborative Commissioning initiatives, including Living Well, Your Way.
Champions: Staff who have advocated and led PRMs adoption within their practice. They have driven activities to support implementation of PRMs within their practice teams, working to integrate into local workflows and develop processes to support practices with long-term sustainable adoption.
Agents: MLHD PRMs managers, MLHD Collaborative Commissioning team, MPHN Primary Care Engagement and Monitoring & Evaluation teams and ACI PRMs Primary Care team.
Governance
Governance mechanisms between MLHD and general practice align with the current LHD governance and reporting structures, including reporting implementation data to the MLHD PRMs Steering Committee. PRMs collection numbers, as well as individual and service level outcomes are reported through LHD reporting mechanisms.
MPHN reporting requirements include initiative outcomes and contract reporting requirements for the GPs. To support PHN reporting of initiative outcomes, the MPHN Collaborative Commissioning Monitoring and Evaluation Manager can access de-identified aggregated service and system level data via the HOPE Manager role and pull this data into Power BI dashboards to present outcomes. This reporting has included all LHD and primary care reporting for COPD/respiratory and congestive heart failure (CHF) patients collecting PRMs in HOPE.
General practices also complete a HOPE participation agreement with the ACI, outlining the roles and responsibilities in protecting personal health information collected when administering PRMs using HOPE. The participation agreement is underpinned by the PRMs Data Governance and Management Framework.
Four practices expressed interest in trialling PRMs using HOPE as part of Collaborative Commissioning and other PHN initiatives. Living Well, Your Way is a joint initiative between MPHN and MLHD funded by the New South Wales Ministry of Health. Collaborative Commissioning is subject to its own governance processes, including incorporating PRMs-HOPE considerations into relevant contracts, local data sharing agreements and reporting deliverables with participating practices.
Acknowledgements
We acknowledge and thank the following for their participation in this project:
- Joanne Leonard, Program Manager for PRMs
- Jodie Cicolini, Program Manager for PRMs
- Sandra Gray, Practice Manager, Finley Medical Centre
- Dr Alam Yoosuf, Practice Principal, Finley Medical Centre
- Joanna Loughridge, Practice Nurse, Finley Medical Centre
- Andrew Heap, Senior Manager Primary Care Engagement
- Carolyn Ripper, Program Manager (Primary Care)
- Caroline Holtby, Program Director, Murrumbidgee Collaborative Commissioning