Providing high value care in high demand allied health services: An example of group education in chronic Kidney disease

Mrs Hilary Powlesland1, Mrs Belinda  Mason1, Dr  Riley  O’Donohue2, Dr  Adrian  Kark3, Dr  Lynda J  Ross1,4, Dr  Adrienne  Young1

1Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Brisbane, Australia, 2Department of Psychology, Royal Brisbane and Women’s Hospital, Brisbane, Australia, 3Department of Renal Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia, 4Menzies Institute Queensland, Gold Coast campus of Griffith University, Gold Coast, Australia

Rates of Chronic Kidney Disease (CKD) have increased by 50% over the past decade, placing significant demand on renal healthcare services. In dietetics, international CKD guidelines recommend individualised education to reduce excess dietary sodium intake. However, >80% of outpatients attending Brisbane metropolitan CKD service were identified as needing dietetic intervention for excess sodium intake, thus contributing to long wait-times. This study aimed to determine whether group-based sodium reduction education represents high value care: effective (reduces sodium intakes), efficient (reduces dietetic time and wait-times), and acceptable to patients. A single ninety-minute dietitian-led group-based education session was developed with input from the team psychologist, for patients with high sodium intake (score ≥50 on Scored Sodium Questionnaire-Short Form; SSQ-SF). The session included label reading, myth busting, food swaps and goal setting to increase knowledge and self-efficacy. Four pilot groups were conducted (Feb-May 2018). Sodium intake was measured pre- and six weeks post-group using the SSQ-SF, with comparisons made using Wilcoxen signed rank test. Data was collected on attendance, satisfaction (using validated Short Assessment of Patient Satisfaction) and wait-times. Twenty-three patients attended one of the four groups (30 referred; 77% attendance rate). A clinically and statistically significant reduction in dietary sodium intake was achieved in 78% patients (SSQ-SF score pre-group median: 70, IQR 56-96; post-group: 54, IQR 26-63, p<0.001). All patients reported being satisfied/very satisfied with the group. Dietetic education time was reduced by 30 minutes/patient, reducing wait-time by 12 weeks (pre:7 months; post:4 months), and thus 19 new dietitian appointments were created. Delivering dietetic education to CKD patients in a group setting represents high value care; that is, effective patient outcomes and high satisfaction for less health care resources, and opportunity to reinvest dietetic time for higher priority patients. Group education should be considered by allied health services experiencing high service demand.


Biography:

Hilary Powlesland is an Accredited Practising Dietitian, and has worked for ten years across four major tertiary hospitals, with Bachelor Degrees in dietetics and business. She currently works as a Senior Dietitian at the Royal Brisbane and Women’s Hospital, with a special interest in the areas of Renal, Maternity and Bariatric Surgery. Hilary is the Chair of the Dietitians Association of Australia Queensland Engagement and Development Committee, and was last year presented with a DAA Award of Merit for her leadership and contribution over the past eight years.

Integrated systems, interdisciplinary teams, full scope practice and delegation to deliver better value healthcare? A SIMPLE case for change

Dr Jack Bell1,2, Dr Adrienne Young1, Jan Hill3, Dr Merrilyn Banks1, a/Prof Tracy Comans2, Rhiannon Barnes4, Professor Heather  Keller5

1Metro North HHS, , , 2The University of Queensland, , , 3Metro South HHS, , , 4Queensland Health, , , 5University of Waterloo and Schlegel Reseach Institute, , Canada

Aim: A paradigm shift is required to manage increasing patient throughput and demand on allied health services in acute hospitals. Systematised, Interdisciplinary Malnutrition Program Implementation and Evaluation (SIMPLE) aims to provide better nutritional care to hospital inpatients without increased dietetic resources. This study describes quantitative findings associated with implementing the SIMPLE approach to managing malnutrition in six Queensland hospitals, and provides a case example for successful interdisciplinary and delegated models of care reform.

Methods: A multisite before-and-after design to evaluate the impact of SIMPLE program implementation across 6 Queensland hospitals. A combination of systematised, interdisciplinary and delegated nutrition care interventions were tailored to fit individual sites using a facilitated implementation science approach. Documented and observed practices were audited and used with patient reported outcomes to evaluate success.

Results: Audit data was available for 1036 patients (median 72 years, male 52.9%, malnutrition risk of 44.6%). Preliminary findings for 5 sites compared nutritionally at-risk patients audited at baseline (n=168) with at-risk patients audited 5-6 months after SIMPLE implementation (n=174). Significantly improved inpatient food and nutrient delivery (67.9 versus 83.9%; χ(1) 12.081, p=0.001) and coordination of care (45.8 versus 57.5%; χ(1) 4.636, p=0.031) processes were observed following early implementation of the new model. A non-significant improvement was observed for nutrition education processes (44.0 versus 52.9%; χ(1) 2.666, p=0.103). No additional clinical funding was provided and there was no significant increase in median dietitian occasions of service associated with implementation (p=0.686). Trends towards increased delegation to assistant staff were also observed (p=0.082).

Conclusions: Shifting to a model of care that supports integrated, systems based approaches, healthcare teams working together, full scope of practice, and appropriate delegation improves audited and patient reported outcomes. When this is delivered without an increase in clinical funding, this equals better value healthcare and makes a SIMPLE case for change.

(This study was supported with grants from the Allied Health Professions Office of Queensland, and The Australian Centre For Health Services Innovation (AusHSI))


Biography:

Dr Bell is an advanced dietitian, a conjoint Principal Research Fellow with University of Queensland and Metro North Hospital Health Service, and a current MRFF TRIP Fellow. As an implementation scientist Jack currently works with teams across Queensland and Canada to implement systematised, interdisciplinary malnutrition care in hospitals. As a member of the Queensland Clinical Senate and Metro North Clinical Council Jack advocates for high value healthcare and better work/life balance.

Opportunity for delegation and interdisciplinary nutrition care in acute stroke units

Margot Leeson-smith1, Claire Archer2, Grace Carson3, Juliette  Mahero4, Liliana Botero Zapata1, Adrienne Young1

1Nutrition and Dietetics, Royal Brisbane And Women’s Hospital, Herston, Australia, 2Nutrition and Dietetics, Caboolture Hospital, Caboolture, Australia, 3Nutrition and Dietetics, Redcliffe Hospital, Redcliffe, Australia, 4Nutrition and Dietetics, The Prince Charles Hospital, Chermside, Australia

After stroke, nutritional risk related to dysphagia, fatigue, difficulty self-feeding and reduced appetite is common. International stroke guidelines recommend malnutrition screening and regular nutrition monitoring throughout the acute stroke admission. With increasing demands on allied health services, it is important to explore options for delegation and interdisciplinary care models. This study aims to describe nutrition care practices across acute stroke units in four Queensland hospitals, with the purpose of identifying opportunities for delegation and interdisciplinary care. Data were collected on consecutive patients admitted with acute stroke (August – November 2018): nutrition risk (defined as Malnutrition Screening Tool score ≥2, dysphagia requiring a texture modified diet and/or requiring feeding assistance), nutrition care initiated (diet code, food intake monitoring) and by who (dietitian, dietetic assistant, nursing, other), and indication for dietetic input (malnutrition diagnosis, enteral tube feeding need). Descriptive statistics (%, counts; mean, SD) were used to analyse data. Audits included 97 patients (average age 70 years, 52.5% male); five patients excluded due to palliation. Almost all patients were placed on oral diet (95%, n=92/97); of these, 48% (n=44/92) were identified as nutrition risk. Sixty-six percent (n=29/44) of at-risk patients received an appropriate high protein/energy diet, initiated mostly by dietitians (59%; dietetic assistants: 24%, nursing: 15%, speech pathology: 2%); less than half received food intake monitoring (39%, n=17/44), initiated mostly by the dietitian (56%; dietetic assistants: 24%, nursing: 20%).  Despite half of patients being at nutrition risk, only 7% (n=7/97) were malnourished and 5% (n=5/97) required enteral tube feeding. This study highlights opportunities for delegation and interdisciplinary care models in acute stroke, due to the high number of at-risk patients requiring monitoring and support but only a small number needing expert dietetic input. Implementation and evaluation of a systematised, interdisciplinary and delegation model is currently underway.

This study was supported with a grant from the Allied Health Professions Office of Queensland.


Biography: To be confirmed

Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review

Dr Mitchell Sarkies1

1Curtin University; Monash University,

BACKGROUND: The routine provision of additional allied health services during weekends is variable across hospitals both in Australia and worldwide. It is unclear whether providing these services is beneficial. The aim of this review was to synthesise available evidence examining the effectiveness and cost-effectiveness of providing additional weekend allied health services to patients on acute general medical and surgical hospital wards, and subacute rehabilitation hospital wards.

METHOD: A systematic review and meta-analysis of studies published between January 2000 and May 2017 was conducted. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality. Meta analyses were conducted for relative measures of effect estimates. Studies were included if they focussed on patients admitted to acute general medical and surgical wards, and subacute rehabilitation wards. Interventions of focus were all services delivered by allied health professionals during weekends. This study limited allied health professions to: occupational therapy, physiotherapy, social work, speech pathology, dietetics, art therapy, chiropractic, exercise physiology, music therapy, oral health (not dentistry), osteopathy, podiatry, psychology, and allied health assistants. Outcome measures of interest included: hospital length of stay, hospital re-admission, adverse events, discharge destination, functional independence, health related quality of life, and cost of hospital care.

RESULTS: Nineteen articles (20 studies) were identified, comprising 10 randomised and 10 non-randomised trials. Physiotherapy was the most commonly investigated profession. A meta-analysis of randomised controlled trials showed that providing additional weekend allied health services in subacute rehabilitation wards reduced hospital length of stay by 2.35 days (95% CI 0.45 to 4.24, I2 = 0%), and may be a cost-effective way to improve function (SMD 0.09, 95% CI –0.01 to 0.19, I2 = 0%), and health-related quality of life (SMD 0.10, 95% CI –0.01 to 0.20, I2 = 0%). For acute general medical and surgical hospital wards, it was unclear whether the weekend allied health service model provided in the two identified randomised trials led to significant changes in measured outcomes.

CONCLUSION: The benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.


Biography:

Mitchell Sarkies is a physiotherapist and health services researcher who is interested in the implementation of evidence into healthcare policy and practice.

Does mobilisation on the day of hip or knee replacement surgery reduce hospital length of stay?

Dr Michael Murphy1,2, Ms Mel Hortz1

1Mater Health, Brisbane, Australia, 2The University of Queensland, St Lucia, Australia

Hip and knee arthroplasty volume has increased dramatically in the past decade increasing pressure on health care service capacity and resources. The challenge for service providers is to continue to provide high quality evidence based care, but to do so as efficiently as possible. A key area of cost reduction and increasing capacity is reducing hospital length of stay (LOS). Enhanced Recovery after Surgery (ERAS) programs are multifaceted models of care which improve efficiency and have demonstrated effectiveness in reducing LOS. In the orthopaedic setting one part of ERAS is commencing mobilisation on the day of surgery (DOS), but few studies have isolated its effect on LOS.

A retrospective audit of patients who underwent unilateral primary hip or knee arthroplasty at the Mater Hospital Brisbane was conducted to determine the LOS of patients who had mobilised successfully with physiotherapists on the DOS. Other outcomes included American Society of Anaesthesiologists’ (ASA) score, which assesses overall physical health, age and reason for unsuccessful mobilisation.

Patients who successfully mobilised on the DOS had significantly shorter LOS compared to those who did not (4.3days±1.8, 5.1±1.8, p<0.001). There was no significant difference in age between mobilising and non-mobilising groups (69.5±8.4, 69.0±9.9, p=0.71), or in ASA (2.31±0.6, 2.46±0.63, p=0.06). Importantly only 20% of eligible patients were given the opportunity to mobilise (mobilised n=74, not mobilised n=299). The main reason for not mobilising was staffing, with 53% of non-mobilised patients returning to the ward after physiotherapists’ shifts had concluded, and 15% transferred to intensive care for other comorbidities, where staff were not familiar with the mobilisation protocol.

This audit demonstrated that mobilising patients on the DOS significantly reduces LOS. Further development of this protocol will focus on multidisciplinary systemic restructuring including physiotherapy staff rostering, operating theatre timing and staff and patient education.


Biography:

Michael Murphy is an advanced practice physiotherapist in orthopaedics at Mater Hospital Brisbane involved with clinical education, research and an expanded scope arthroplasty review clinic.

Guardianship in hospitals: A health services/OPA pilot program

Ms Dina Watterson1, Ms Fiona McAlinden2, Mr Tass Kostopoulos3, Mr Paul Newland4

1Alfred Health, Melbourne, Australia, 2Monash Health, Melbourne, Australia, 3Eastern Health, Melbourne, Australia, 4Office of the Public Advocate (Victoria), Melbourne, Australia

Background: This collaborative project between three metropolitan health services and the Office of Public Advocate Victoria (OPA) explores the impact of increased availability of advocate guardians delegated by the Public Advocate on healthcare system value, sustainability and outcomes. The pilot targets a particularly-vulnerable group: hospital-based recipients of VCAT guardianship orders, made on evidence of a cognitive impairment indicating a lack of capacity to make important lifestyle and personal decisions. The primary aim of the pilot is to reduce the time these patients spend waiting for allocation of a guardian, decreasing patient risk and increasing value by releasing healthcare system resources.

Method: A multi-institutional, cross-sectional pilot program created a dedicated hospital guardian team within OPA, funded by the partner health services, to reduce the time to guardian allocation for patients within these services. The impact of the pilot was measured through an historical control group design, with initial data collection over 12 months, followed by yearly cohorts of post-implementation patients.

Results: Under this pilot the time from guardianship order lodgement to guardian allocation has significantly decreased from 46.5 to 23.1 days, halving the average time hospital-based patients spend waiting for a guardian. Estimated cost savings are $15,355 per patient, or over $5 of healthcare system resources released per $1 spent on increased staffing.

Discussion: These findings demonstrate how collaboration and investment by healthcare providers in non-health areas can deliver substantial benefits for healthcare system value and sustainability in an area of patient vulnerability and growing demand.


Biography: To be confirmed

Understanding patient factors associated with weight gain and weight loss after knee or hip arthroplasty: An opportunity to increase the value of this expensive intervention

A/Prof Justine Naylor1,2,5, Dr Kathryn Mills3, Ms Natasha Pocovi3, A/Prof Sarah Dennis1,4,5, Ms Danella Hackett1, Dr Leanne Hassett1,4, Dr Bernadette Brady1, Ms Adriane Lewin2, Dr Sam Adie2, Dr Wei Xuan2,5

1SWSLHD, Liverpool Bc, Australia, 2SWS Clinical School UNSW, Liverpool BC, Australia, 3Macquarie University, Ryde, Australia, 4University of Sydney, Lidcombe, Australia, 5Ingham Institute for Applied Medical Research, Liverpool, Australia

Background:
Following total knee or total hip arthroplasty (TKA, THA), up to 31% of recipients experience significant weight gain while up to 14% experience significant weight loss. Factors associated with significant weight change (≥ 5%) have not been comprehensively explored. This study aimed to identify pre- and post-surgical (including current) patient factors associated with significant weight change three years after surgery.

Methods:
A pre-existing nationally-acquired cohort who underwent TKA or THA for osteoarthritis participated in 3-year telephone follow-up. Updated weight, comorbidity, and complication data were collected along with participation in regular physical activity, ongoing index joint problems, and other patient-reported outcomes. These data, along with body mass index (BMI) pre-surgery and post-surgery rehabilitation received, were incorporated into two multivariable logistic regression models to determine the factors associated with ≥ 5% weight gain and ≥ 5% loss at 3-years post-surgery.

Results:
73.4% (1289/1757) participated in the follow-up; 1191 (n = 663 TKA) provided updated weight data. Patterns of weight change were similar for both surgeries (TKA: 16.1% gained ≥ 5%, 19.6% lost ≥ 5%; THA: 15.8% gained ≥ 5%, 17.8% lost ≥ 5%). In multivariable modelling, younger age and lower pre-surgery BMI were significantly associated with weight gain; female gender and an absence of ongoing index joint issues were associated with weight loss.

Discussion & Conclusion:
Different mechanisms are likely associated with significant weight gain or loss at 3-years post-surgery. Cogent weight management entails consideration of both outcomes. Allied health clinicians have a role in promoting weight management as part of post-surgery rehabilitation as well as during the prehabilitation phase. Better weight management should lead to improved patient outcomes and ultimately better value healthcare from the perspective of all stakeholders.


Biography:

A/Prof Justine Naylor is a physiotherapist and senior principal research fellow in Orthopaedics at SWSLHD, and a Conjoint A/Prof at UNSW. She has published widely in the orthopaedic literature especially in the arthroplasty field. She has research interests directed at improving the value of care provided for arthroplasty patients and improving outcomes following surgery.

NAHC Conferences

2007, Hobart (7th NAHC)

2009, Canberra (8th NAHC)

2012, Canberra (9th NAHC)

2013, Brisbane (10th NAHC)

2015, Melbourne (11th NAHC)

2017, Sydney (12th NAHC)

2019, Brisbane (13th NAHC)

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