Integrating a multidisciplinary “Stepped” Model

psychosocial Care for cancer survivors and

families into routine clinical practice in rural

and remote regions.

Catherine Adams

Senior Clinical Psychologist

Stream Co-Ordinator

HNELHD Psycho-Oncology Clinical Stream

Acknowledgements

• Deanna Sue

• Fiona Ord, Jann Tuart, Judith Conning and

Lee Smith

• Brian Kelly

• Anthony Proietto, Jill Lack and Doug Bellamy

• All the staff, volunteers, GP’s, practice nurses,

and interested parties who participated.

Background

• HNELHD covers an area the size of the UK and has the state’s largest proportion

of aboriginal people.

• Four (3.0 FTE) dedicated Psycho-Oncology Social Workers based in Taree,

Tamworth, Armidale and Moree.

• No dedicated Clinical Psychology or Psychiatry positions.

• Plan to introduce a “stepped” Model of Care (MOC) into multidisciplinary teams

across the rural and remote areas of the Hunter New England Local Health District

(HNELHD).

• Crucial need to involve all local members of the psychosocial care team

• And also develop strong telehealth links for specialist care for patients and their

families/carers

The “Stepped” Model of Care

HNELHD generic psychosocial care pathway

Aims

1. Improve multidisciplinary team connections between rural,

remote and metropolitan multidisciplinary teams, including

GP, community Aboriginal health and acute care providers

through:

– development of local psychosocial care networks based on the

stepped MOC and using existing resources.

– tailored services promoting access for high priority populations though

linkages with relevant agencies and services as required

2. Provide skills based psycho-oncology training to health care

providers, including community, Aboriginal health and GPs

Aims

3. Investigate use of technology to enhance psycho-

oncology care provision

4. Work within the stream to foster better

understanding of Aboriginal cultural and health issues

to provide appropriate support

Method

• Identified local networks

• Organised workshops where possible

• Provided training in effective partnerships and

communication skills

• Investigated methods of integrating telehealth

options into routine clinical care and also

professional development.

The local networks

• Moree 7hrs or 500km to Newcastle

– 0.5FTE SW, Med Onc from

Tamworth

• Armidale 4hr30min or 350km

– 0.5FTE SW, (Private Med and Rad

Onc from RNSP)

• Tamworth 3h40m or 281km

– 1.0FTE SW, Haem, Med and Rad

Onc onsite, NWCC

• Taree 2hrs or 170km

– 1.0FTE SW, Med Onc onsite

• Muswellbrook 1h40m or 125km

– 0.0FTE SW, Med Onc from

Newcastle/Tamworth

Results

• Network meetings

– Very positive feedback, all found useful

– Increase in knowledge of local services and

support available and confidence in accessing

support and making a referral

– Fewer people felt very confident about referral

– 15 using telehealth, 9 would now use and 4

wouldn’t consider using.

Results

• Professional development

– Effective Partnerships

• Very positive feedback

• Particularly useful for NWCC

• Positive focus on what we can achieve rather than what

we can’t

– Communication Skills

• Very positive feedback as reflected in comments

• Service Directories

– All at different stages…

ResultsServices relevant to mild levels of DistressOrganisations who can provide information, brief emotional and/or practical support:

Services relevant to moderate to severe levels of DistressOrganisations or individuals who can provide supportive or extended care

Services relevant to severe levels of DistressProfessional mental health care Organisations or individuals who can provide diagnosis/management/therapy

Cancer council helpline 13 11 20 Cancer council helpline 13 11 20 Cancer council helpline 13 11 20

Cancer support groups – please add specific details and

contact numbers

Leukaemia Foundation

Men’s Shed

Camp Quality

CanTeen - Now What? Booklet for children dealing with

parent/s with cancer. 1800 669942,

www.nowwhat.org.au

The Hunter and Northern NSW AYA (Youth Cancer

Service) based at Calvary Mater Newcastle for 15-25 year

olds. Email ayaccn@calvarymater.org.au

Prostate Cancer Support Group

Telephone helpline 131120

Can Assist

Cancer Connect

Information service in Armidale Hospital Oncology Unit

provided by the Cancer Council

Wig Library from a private home

Carer Support Group – HNE Community Health

Cancer Awareness Centre – supportive contact,

counselling, massage, wellbeing. Current contact

0409722149

Cancer Council Webinars both professional and

consumer focused

HNE Telehealth Wellbeing Program - is this still open to

new patients?

Armidale hospital

Social Worker – both general and oncology

Palliative Care

McGrath Breast Cancer Nurse

Cancer Care Coordinator

Pastoral Care

Other services

Beyond Blue – (this appears under the hospital heading, feel free to

relocate it within the directory as appropriate)

Cancer Council Helpline –Social Workers/Psychologists over the

phone, providing a free service

Private Psychologists – I have written “referral pathways directory”

after this, but have forgotten the context. Can someone please clarify?

ie Amanda Akers will bulk bill? (not sure if this is correct), need to

add others to this list

General Practitioners - can provide Enhanced Primary Care plan, or

Mental Health Care Plan as appropriate. Practice Nurses also

provide triage to appropriate supports

New England Medicare Local – Connecting Care Program for Chronic

Disease Management, can include cancer if this co-exists with

another chronic disease such as COPD, Diabetes, Hypertension

Chronic Heart failure, Coronary Artery disease, and person is over

16, with 3 or more unplanned admissions to hospital within a 12

month period.

Aboriginal or Torres Strait Islanders can access Care Coordination

and Supplementary services for chronic disease management if

enrolled with a GP or indigenous Health Service/ ACCHO, have a care

plan and a referral from the GP

Telehealth using Scopia virtual meeting rooms,

prefer that initial consultations are conducted

face-to-face. Can we clarify why this is preferred for

the purpose of the directory please?

Telepsychiatry –

https://ranzcp.org/Publications/Telehealth-in-

psychiatry.aspx website with more information

for clinicians and patients

Video case conferencing monthly with Psycho-

oncology JHH

NEML Scopia consultations/GoTo meeting – see

www.neml.org.au/telehealth -> specialist

directory

Some psychologists perhaps? Need to identify

locally who

Mental Health service within Armidale Hospital

Implications

• Interdisciplinary partnerships

– GP’s

– Across existing teams

• Adoption of pathway

– Difficulty with point of entry screening

• Efficient resource usage

• Engagement

• Broad application

Future Plans

• World domination

• Developing stronger links with Aboriginal

Cancer Services and local AHS

• Working with GP networks and developing

healthcare pathways

• Refining the service directories

• Integrating feedback on progress in Psycho-

Oncology Clinical Stream Meetings

• One day at a time…