The South Western Sydney Primary Health Network (SWSPHN) COVID-19 Monitoring Pilot Project ran in 2022-2023. It introduced a nurse-led medical neighbourhood model to help participating general practices manage large numbers of COVID-positive patients in the community.
By using Patient Reported Measures (PRMs), the project aimed to identify patients with symptoms of long COVID, both to ensure they received the appropriate level of care, and to understand the prevalence within the community.
The project included PRMs in the following ways:
- A trial involved follow-up with patients from the participating general practices using the Health Outcomes and Patient Experience (HOPE) platform. HOPE was used for the electronic collection of Patient Reported Outcome Measures (PROMs) to identify patients with symptoms of long COVID. PROMs used included the Post COVID-19 Functional Status Scale (PCFS) and COVID-19 Yorkshire Rehabilitation Scale (C19-YRS).
- Evaluation data derived from surveys conducted was used to assess both patient and clinician experiences with the program.
- Aggregated de-identified PRMs data from the HOPE platform was used to provide insights into outcomes regarding long COVID follow-up.
Patient-reported measures workflow
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Nurses from participating practices conducted telehealth monitoring for COVID-positive patients using a range of virtual tools and software. Nurses escalated the case to the referring general practitioner (GP) if their condition worsened.
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After the monitoring period, nurses provided summary reports to GPs, and patients resumed care with their usual GP.
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Patients completed follow-up surveys via the HOPE platform to screen for long COVID symptoms. All patients completed the PCFS. Those who scored 1 or above in the PCFS were automatically assigned a C19-YRS via HOPE.
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Survey responses were reviewed and discussed with the patients and additional clinical management was arranged as needed.
Consumer story
A patient at Mt Gibraltar General Practice presented with long COVID. They completed two PRMs, the PCFS scale and the COVID-19 YRS. These were used to inform the patient’s GP management plan, including treatment with a physiotherapist and referrals to a cardiologist and rheumatologist. Following physiotherapy treatment, the patient completed another C19-YRS, which showed improved results for pain, sleep, weakness and muscle pain. These results also helped the patient identify their next management priority and focus on taking manageable actions. The patient reported that they felt greater control over their health and more empowered to making changes.
PRMs help patients to feel genuinely heard when they share information, validates how they are feeling and flags any issues for future conversations with their GP. PRMs help to make the patient responsible for reporting their symptoms and helps make clinicians accountable to their patients for clinical care and follow-up (in particular with the C19-YRS, depending on responses). As a practice nurse, information from PRMs is helpful and can easily be shared with the doctor via the patient file and action list.
Benefits of patient-reported measures
Benefits for the patient
- Patients gained awareness of their health status, empowering them to act if early symptoms were detected.
- Patient surveys showed satisfaction with their healthcare and better understanding of their COVID diagnosis.
Benefits for the service
- Providers could access real-time symptom data, aiding resource allocation and reducing GP workload.
- Overall, clinicians reported positive program impact, with some being able to reduce face-to-face consultations
Benefits for the organisation
- Aggregated PROMs data informs epidemiological surveillance, guiding containment strategies and resource allocation for long COVID management across the system.
Helpful tips for other services
Work with practice staff to embed PRMs within existing workflows of the practice and service.
Choose PRMs that are meaningful to your demographic and capture what you want to know about your consumers.
Include PRMs funding within program contracts to ensure protected staff time to implement PRMs.
Clinical engagement approach
The initial pilot was scheduled for six months, with five established general practices in SWSPHN expressing interest and four of these sites adopting the HOPE platform.
The ACI PRMs Primary Care team provided onboarding services to each practice, which included onsite training and implementation support over two visits. Refresher training was also offered to any new staff. This was followed up with fortnightly virtual follow-ups over the remainder of the trial period.
The initial pilot was later extended for an additional six months, with four participating practices continuing until April 2023.
Organisational structure
Within SWSPHN, there was a dedicated project coordinator who collaborated with the ACI Primary Care team and the COVID-19 Response Team to facilitate the project rollout and monitor the implementation of PRMs. The project coordinator reported to the Director of Innovation and Partnerships at SWSPHN and had regular meetings with ACI PRMs project partners.
A formal participation agreement was established with the principal of each participating general practice. The practice nurse and practice manager from each practice was responsible for championing the project and monitoring the implementation of PRMs and HOPE, with the support of SWSPHN and ACI.
Governance
Strategic direction was provided by the NSW Primary Health Network (PHN) CEO Group to pursue a standardised approach to PRMs collection with NSW Health. The aim was to adapt and adopt the PRMs process so it was fit for purpose for primary care, including data governance and management requirements. SWSPHN was selected as one of three PHN trial sites to trial this joint approach.
Within SWSPHN, executive sponsorship and resourcing was provided, enabling the inclusion of PRMs and HOPE into the pilot project practice agreement, and for the COVID-19 response team to be engaged and supportive of PRMs use.
General practices were required to complete a HOPE participation agreement between the ACI and the practice, outlining the roles and responsibilities in protecting the personal health information involved in administering PRMs using HOPE. This participation agreement is underpinned by an existing PRMs Data Governance and Management Framework.
Acknowledgements
- SWSPHN COVID-19 Response and Special Projects teams
- The ACI PRMs Primary Care team
- Four general practices from SWSPHN