Embracing the Chronic Care

Model

Danella Hackett

Snr Physiotherapist, Musculoskeletal Coordinator

Fairfield Hospital

Susan Dietsch

Orthopaedic Clinical Nurse Consultant

Fairfield Hospital

March 2018

Outline

Our Chronic Care Journey at Fairfield

What does team work look like in the OACCP at Fairfield

What has helped us get to where we are today

How do we embrace multicultural care at Fairfield

Case Study

Osteoarthritis – Chronic Care Problem

2.1 mill or 9% of the population has Osteoarthritis(AIHW 2017)

Prevalence higher for the Aboriginal population compared

to rest of Australia (AIHW 2017)

Current trends suggest by 2050, 7 million Australians will

be affected by some form of arthritis (Arthritis Australia)

Co morbidities – Chronic Care

Problem

Initial Program

Physiotherapist Assessment

clients reviewed every 4 months with mail out of questionnaires

Problems

– Repetitiveness of education

– Loss to follow up without face to face contact

– Multiple co-morbidities impacting on timing of surgery

– Resources

Fairfield Team Orthopaedic CNC and

Musculoskeletal Coordinator and

Administrative support

Fairfield OACCP commenced in

2010

Assisted ACI develop the OACCP

model of care which we are all a part

of today

The Expansive chronic care team

GP and Surgeon

Diabetes Educators (Hospital Clinics / GP’s)

Cardiac Rehabilitation

Pulmonary Rehabilitation

Community Exercise Facilities/Programs (Get Active and

Healthy)

Get Healthy

Drug and Alcohol services

Aboriginal Chronic Care Coordinators

My Aged Care

Stepping on and Falls Prevention Programs

Private Practitioners through Chronic Care Plans

Psychologists through Mental Health Care Plans

Enablers

Staff completed Health Change Australia course October

2011 and July 2012 to improve behaviour change

outcomes

Changes to program elements

– Education format

– Interchangeable clinical roles

– Phone support

Enablers

Having a local Champion

Administrative support

Co location

Complete Quality Improvement Activities

Clinical Management of the Orthopaedic Waiting list

Feedback mechanisms and close relationships with

Orthopaedic Surgeons

– Weekly meetings

– Phone and Email contact

Tap into existing resources

– Consider who you can access and develop networks with

programs and services which already exist

Enablers

Observations with Implementation locally

More clients medically fit for surgery at final preadmission

appointment

0%

10%

20%

30%

40%

50%

60%

Jan-Mar 2011 Jan-Mar 2012

Pre-admission cancellations

Embracing Multicultural Care

Most recent work has looked at access for the CALD

community to our OACCP compared to the English

speaking population

At Fairfield 53% of people are born in another country and

17.4% of the Fairfield population are proficient in English (SWSLHD 2016)

5% of the CALD community who require interpreters to

complete their appointment could access an initial

appointment within 1 month compared with 35% of English

speaking patients..

Quality Project

Used Quality improvement methodology that the CEC

provides education around

Changed our processes so it was more equitable

1st place at SWSLHD District Quality awards and was a

finalist (top 3 in the state) at the NSW Health Awards 2016

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan

uar

y-Ju

ne

20

13

July

-Dec

emb

er 2

01

3

Jan

uar

y-Ju

ne

20

14

July

-Dec

emb

er 2

01

4

Jan

uar

y-Ju

ne

20

15

July

-Dec

emb

er 2

01

5

Jan

uar

y-Ju

ne

20

16

July

-Dec

emb

er 2

01

6

Jan

uar

y-Ju

ne

20

17

July

-Dec

emb

er 2

01

7

Jan

uar

y-Ju

ne

20

13

July

-Dec

emb

er 2

01

3

Jan

uar

y-Ju

ne

20

14

July

-Dec

emb

er 2

01

4

Jan

uar

y-Ju

ne

20

15

July

-Dec

emb

er 2

01

5

Jan

uar

y-Ju

ne

20

16

July

-Dec

emb

er 2

01

6

Jan

uar

y-Ju

ne

20

17

July

-Dec

emb

er 2

01

7

English Speaking Interpreter Required

Percentage of clients completing an Initial FOHKS Appointment within 1 month of referral

Project Initiated

Project Initiated

Inequality in Access for CALD

community identified

Case Study Mr A

72 year old Vietnamese Speaking Male Awaiting Left TKR

BMI 36

PMHx: Type 2 Diabetes Mellitus with unstable diabetes on

day of appointment BGL 2 hours post meal 13.2mmol,

Hypertension, 2 falls in the last 6 months,

SHx: Lives with his wife who is well. Completes all

domestic tasks. Lives in Single storey house with 4 steps

to access the house

Team Work at Fairfield

CNC

Review of blood pressure elevated on the day

156/93mmHg

Blood Results from GP – HbA1c 9.5%

Cardiologist review and clearance required for surgery

Physio

Review of mobility – Education provided on walking aids

and Mr A purchased SPS

Falls prevention exercises and referral to Able and Stable

Follow up

Follow up phone call

Review at 3 months

Follow up phonecall further 3 months

Pre admission clinic

Take Home Message

How can I do things differently???

Who can I get to help me???

What opportunities do I have to make a difference????