Preparing for change in aged care and e-health

The AMA has advocated for some time to secure the appropriate recognition and resourcing of medical care for older Australians. This is even more necessary now given that 15 per cent of the population are over 65 years of age, and the proportion continues to grow.

The Medical Practice Committee, in conjunction with the AMA Council of General Practice, developed a submission in response to the Senate Standing Committee on Community Affairs Inquiry into the Future of Australia’s Aged Care Sector
Workforce.

The AMA argued strongly that the aged care sector must evolve to be able to care for older Australians while preserving a person’s access to quality medical care. The AMA’s submission highlighted that medical practitioners, especially general practitioners, are underutilised in the provision of care for the ageing. This leads to a substandard outcome for the patient, and inefficiencies for the practitioner and the health system.

The AMA also recommended that providers of aged care should have arrangements in place to ensure that residents’ needs for medical care are identified promptly, and that they receive ongoing access to medical care, preferably within the aged care facility. Strategies to achieve this include:

ensuring adequate numbers of appropriately skilled nurses are employed;
having management practices in place to ensure residents who require medical attention from a doctor are identified quickly, and that the appropriate doctor is contacted;
providing doctors with access to properly equipped clinical treatment rooms that provide patient privacy; and
providing doctors with access to information technology infrastructure, and patient records, so ensure continuity of care.

The key message is that medical practitioners are an essential component of the aged care workforce.

The AMA submission was lodged on 4 March and is published on the AMA’s website at: submission/ama-submission-senate-community-affairs-in…

Medical Practice Committee is also reviewing the AMA’s policy and position on shared electronic medical records.

In March this year, the Government relaunched My Health Record (previously the Personally Controlled Electronic Health Record), announcing two trials of ‘opt-out’ arrangements as the basis for patients to participate in, as well as a new legislative framework.

The ongoing review and updating of our policies will ensure a rapid and informed response to any new Government proposals as a result of the trials.

We will be reviewing the AMA’s position statement Shared Electronic Medical Records (2010) to ensure it still clearly defines the needs of clinicians in relation to shared electronic medical records.

Of particular concern is a requirement that core clinical information is reliably available (not subject to access controls); that governance arrangements include the real involvement of clinicians; and that medical specialists and GPs are supported to make full use of electronic medical records.

I welcome any comments on either the AMA’s position on aged care or electronic medical records to ama@ama.com.au.

Vaccination objection rates haven’t changed: study

Despite media reports to the contrary, the overall level of vaccination objection has remained largely unchanged since 2001.

Research published in the Medical Journal of Australia looked at the trends in registered vaccination objection and estimated the contribution of unregistered objection to incomplete vaccination among Australian children.

Dr Frank Beard and colleagues from the National Centre for Immunisation Research and Surveillance at The Children’s Hospital at Westmead and the University of Sydney found that registered objectors affecting children from 1 – 6 had increased from 1.1% in 2002 to 2.0% in 2013.

However the proportion of children with incomplete vaccinations but no objection recorded declined during this period.

The authors also found that more than half of the 2.4% of children with no vaccinations recorded were born overseas.

It’s suggested that most of these children are likely to be vaccinated however they haven’t been recorded on the Australian Childhood Immunisation Register.

“We recommend that primary care clinicians pay close attention to ensuring that the vaccination history of overseas-born children is correctly recorded in the ACIR,” the authors urged.

The authors estimate 1.3% of children were incompletely vaccinated due to unregistered parenting vaccination objection. In total, an estimation of 3.3% of children were affected by registered or unregistered objection.

A 2001 survey found that 2.5-3.0% of children had parents who had registered an objection, suggesting “that there has been little change in the overall impact of vaccination objection since 2001”.

The authors urged GPs to be on the lookout for appropriate catch up opportunities for under vaccinated children.

Latest news:

Fight to save GP research BEACH project after closure announced

The medical community has been in uproar this week with the announcement that Australia’s largest GP research program, the Sydney University BEACH project, would be shut down in June this year.

BEACH has been running for 18 years and collects information about clinical activities in general practice.

Its closure will leave: “very little reliable, independent national information about GP clinical activity in the future,” Director of the Family Medicine Research Centre, University of Sydney, Professor Helena Britt said in a statement.

Professor Britt explained that funding from the Department of Health ceased after June 30^th this year.

“BEACH has always struggled to gain sufficient funds each year. However, this notification comes when we also have a large shortfall in funding coming from other organisations such as NGOs and pharmaceutical companies, due to closure of many Government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits, resulting from changes to the PBS,” she wrote.

However there is hope, with an announcement late on Monday that the University of Sydney is looking into a range of options to ensure the continuing operation of BEACH over the next 12 months while it develops a longer term future plan with the Family Medicine Research Centre.

There has been shock and disappointment felt in the medical community.

RACGP President Dr Frank R Jones said the closure was a ‘bitter loss’.

“BEACH data allows us to measure patterns and change over time, providing valuable insight into the delivery of patient care, including consultation time, the number of problems managed in each encounter, and treatment provided. None of this can be gleaned from the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS) and hospital data,” he said.

Over 5000 citations of the BEACH program have been made in medical journals and publications over the past 18 years, according to Dr Jones.

“There is no logic to this move. It has simply added insult to injury for general practice,” he said.

“BEACH data has made a critical contribution to primary healthcare policy, providing the evidence by which decisions can be made by government.”

The Australian Medical Association President Professor Brian Owler said he had written to Health Minister Sussan Ley to urge her to reconsider.

He said the Commonwealth had contributed just $4.6 million of the $26 million that had been used to fund the BEACH program over the years.

“This is a very small investment that has delivered significant policy outcomes and, with all the changes planned for general practice and primary care, I think there is a very strong case to extend funding for the program,” he said.

Professor Britt told the AMA’s Australian Medicine she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

She said one of the biggest concerns is what will happen to the data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said her group was looking at ways to ensure people would continue to have access to it.

“We would be happy to find a place with a senior analyst who could take request to analyse the data for specific purposes,” she said. “We would like to be able to keep that access up there for at least a little while.”

Latest news:

Get back to the BEACH, Govt told

AMA President Professor Brian Owler has urged the Federal Government to reverse its decision to axe funding for one of the most extensive and sustained studies of general practice in the world, arguing the move is “completely at odds” with its stated primary care focus.

In a decision that has shocked and dismayed medical practitioners and researchers, the long-running Bettering the Evaluation and Care of Health (BEACH) program, which began tracking the activities of Australian GPs in 1998, is being wound up after the Federal Department of Health announced it would not be renewing funding for the research after the current contract expires on 30 June.

Professor Owler has written to Health Minister Sussan Ley urging her to reconsider the move, which he said was particularly ill-considered given major changes planned for primary care.

“Research into general practice and primary care attracts very little funding support in comparison to other parts of the health system,” the AMA President said. “The reality is that we need more of this type of research, not less.”

The Government’s decision to axe its funding for BEACH has come less than two week after Ms Ley unveiled the Health Care Homes initiative to give GPs a central role in improving the care of patients with chronic and complex disease. Simultaneously, the Government is trialling its My Health Record e-health record system and is persisting with a four-year freeze on Medicare rebates.

Professor Owler said the Commonwealth had contributed just $4.6 million of the $26 million that had been used to fund the BEACH program over the years.

The wealth of data on general practice that the program had collected had proven invaluable in driving evidence-based policy development, Professor Owler said, and warned that there was “no credible source of information and analysis that is capable of filling the gap that will be left when the program ceases”.

The program’s director, Professor Helena Britt of Sydney University’s Family Medicine Research Centre, said the Government’s decision to cease its contribution had come at a time when the program was already facing a funding crunch caused by a downturn in contributions from other sources including non-government organisations and pharmaceutical companies.

“BEACH has always struggled to gain sufficient funds each year,” Professor Britt said. “However, this notification comes when we also have a large shortfall in funding coming from other organisations…due to the closure of many government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits resulting from changes to the PBS.

“We therefore have no choice but to close the BEACH program.”

Professor Britt said she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

Professor Britt said the BEACH data, which is drawn from an annual sample of GPs providing detailed information on everything from the hours they work to the diseases and other conditions they treat, was a unique resource, and the program’s closure would “leave Australia with no valid reliable and independent source of data about activities in general practice”.

“BEACH has been the only continuous national study of general practice in the world which relies on random samples of GPs, links management actions to the exact problem being managed, and provides extensive measurement of prevalence of diseases, multi-morbidity and adverse medication events,” a statement issued by the Family Medicine Research Centre said.

The data from the latest BEACH survey, which began in April last year and closed at the end of March this year, is being collated and Professor Britt said she hoped to issue a report on the results, possibly in mid-June.

Asked about the possibility of funding coming from other sources, Professor Britt said it was “early days”.

One of the biggest concerns is what will happen to the rich store of data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said the data was used by a huge range of researchers and organisations, and her group was looking at ways to ensure people would continue to have access to it.

Adrian Rollins

BEACH washed up

Attempts to gauge the effect of big changes to chronic disease management and primary care being planned by the Federal Government have been dealt a blow by revelations one of the most extensive and sustained studies of general practice in the world is facing shutdown.

The long-running Bettering the Evaluation and Care of Health (BEACH) program, which began tracking the activities of Australian GPs in 1998, is being wound up after the Federal Department of Health announced it would not be renewing funding for the research after the current contract expires on 30 June.

The program’s director, Professor Helena Britt of Sydney University’s Family Medicine Research Centre, said the Department’s decision had come at a time when the program was already facing a funding crunch caused by a downturn in contributions from other sources including non-government organisations and pharmaceutical companies.

“We therefore have no choice but to close the BEACH program.”

The announcement has been met with shock and dismay by medical practitioners and researchers. Professor Britt said she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

BEACH’s shutdown comes at a particularly uncertain time for general practice as the Government moves to implement its Health Care Homes model of chronic care while simultaneously trialling its My Health Record e-health record and persisting with a four-year freeze on Medicare rebates.

Asked about the possibility of funding coming from other sources, Professor Britt said it was “early days”.

One of the biggest concerns is what will happen to the rich store of data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said the data was used by a huge range of researchers and organisations, and her group was looking at ways to ensure people would continue to have access to it.

Adrian Rollins

Diabetic life expectancy 12 years less than average person

Two large studies have revealed that people with type 1 diabetes have a large gap in life expectancy compared to the general population.

The studies, published in Diabetologia (the journal of the European Association for the Study of Diabetes), show there has been little improvement in life expectancy for type one diabetics over the last few decades.

The first study examined 5,981 deaths of type 1 diabetic patients in Australia from 1997 to 2010.

Associate Professor Dianna Magliano and Dr Lili Huo from Baker IDI Heart and Diabetes Institute, Melbourne and colleagues found that deaths for those aged under 60 accounts for 60% of the years of life lost for men and 45% for women.

In the 10-39 year age group, they found that the major contribution to years of life lost was endocrine and metabolic diseases whereas in the over 40 age group, circulatory disease was the main contributor.

Overall, the researchers found that people with type 1 diabetes had an expectant life expectancy of 68.6 years, 12.2 years less than the average population (11.6 years less for men and 12.5 years less for women).

They also found the age when diabetes was diagnosed plays a critical role in determining the overall life expectancy.

“Our study shows a slight improvement in estimated life expectancy with increasing age at diagnosis,” they wrote.

They concluded: “Early onset of diabetes tended to be a predictor of premature mortality. Deaths from circulatory disease and endocrine and metabolic disease contributed most to early mortality in type 1 diabetes. For improvements in life expectancy, greater attention must therefore be paid to both the acute metabolic and chronic cardiovascular complications of type 1 diabetes. A failure to address either one will continue to leave type 1 diabetic patients at risk of premature mortality.”

In the second study, health records from the Swedish National Diabetes Register were linked with death records to examine life expectancy of Swedes with type 1 diabetes.

Dr Dennis Petrie from the University of Melbourne and Professor Björn Eliasson from the University of Gothenburg and colleagues found that although the life expectancy for men at age 20 with type 1 diabetes increased by about 2 years between 2002-06 and 2007 – 11, there was no change for women in the same time period.

They also noted that cardiovascular mortality significantly reduced for both men and women over the period which coincided with a large increase of the proportion of the population with type 1 diabetes who reported being on lipid-lowering medication.

“However, similar relative improvements in the general Swedish population for CVD were also observed, which suggests a similar uptake in lipid-lowering medication in the general population.”

The authors conclude: “There is still some way to go in terms of improvement in care for those with type 1 diabetes in order to close the gap with the general population.”

In a linked comment in Diabetologia, Dr Lars Stene from the Norwegian Institute of Public Health notes that the gap in life expectancy has remained largely unchanged since the turn of the millennium.

However he said that it’s perhaps not surprising that life expectancy hadn’t changed in the years outlined in the studies: “The differences in lifetime exposure to hyperglycaemia and other determinants of survival in the two overlapping groups of people with type 1 diabetes examined for mortality during these recent years may not be very different. We know that glycaemic control has long lasting effects.”

Dr Stene said general populations in Sweden, Australia and other countries have seen a recent reduction in cardiovascular mortality, an integral part of diabetes care.

“It is likely that patients with type 1 diabetes have enjoyed some of the beneficial developments that do not involve glycaemic control alone,” he wrote.

Latest news:

Primary Health Networks and Aboriginal and Torres Strait Islander health

One of six priorities set by the Australian Government is for Primary Health Networks (PHNs) to focus on the health of Aboriginal and Torres Strait Islander peoples.1 Announced in the 2014–15 federal Budget, PHNs aim to coordinate primary health care provision especially for those at risk of poor health outcomes. There are 31 PHNs across Australia with several formed from consortia of Local Hospital Networks (LHNs). Operational and flexible funding of up to $842 million was committed for PHNs over 3 years from 2015–16.2 It is timely for PHNs to consider how they will improve health care coordination in partnership with Aboriginal and Torres Strait Islander communities in their respective regions.

Efforts to reduce the high hospitalisation rates of Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) people will require PHNs to build formal participatory structures to support best practice service models. Comprehensive primary health care can then be shaped by the needs of the community rather than by ad hoc factors or reactions to financial incentives and health care funding arrangements.3,4 Collaborations with Aboriginal community controlled health services (ACCHSs) within PHN regions have been recommended.5,6

This article outlines how PHNs might support health services to systematically and strategically improve their responsiveness to Aboriginal people within their boundaries according to ten proposals. These best practice models and examples can assist PHNs to adapt their strategic plans to optimally respond to this priority.

1. Collaborate with ACCHSs

ACCHSs are authorities on comprehensive primary health care matters at the local level4,7 and do much more than just cure illness.8 As authentic representational advocates, they can guide PHN responsiveness to Aboriginal health issues and, with more than 150 services across Australia, there are ACCHSs within the regional boundaries of every PHN.

The predecessors of PHNs — the Medicare Locals — were expected to engage with ACCHSs for many Closing the Gap initiatives, such as the Indigenous Chronic Disease Package (ICDP), from 2008.9 Where meaningful partnerships between ACCHSs and Medicare Locals were established in the delivery of these programs, health outcomes for Aboriginal people substantially improved (Box 1).10

2. Establish an Aboriginal and Torres Strait Islander steering committee

PHNs can foster meaningful Aboriginal community engagement by establishing an Aboriginal and Torres Strait Islander steering committee (and Aboriginal representation on the PHN board) with membership led by ACCHSs representatives inclusive of other Aboriginal health service organisations. Similar partnership forums established between the ACCHS, general practice sectors, and state and territory governments have set Aboriginal health priorities at the jurisdictional and regional level for decades.11 The steering committee aims might be modelled on current partnerships between the LHN and ACCHSs (Appendix 1) to develop a strategic plan across the life course.

3. Establish formal agreements to support the strategic plan

PHNs should aim for partnerships to reorient health services from reactionary care to comprehensive primary health care. For example, in remote Western Australia, a partnership agreement between an ACCHS and state government health services was associated with a reversal of the increasing trend in hospital emergency department attendances among other substantial health improvements in only 6 years (Box 2).12

Partnership agreements between PHNs, ACCHSs and other agencies should support Aboriginal leadership, quality care, accountability and patient-centredness, and should be formalised from non-binding memoranda of understanding to binding contracts (Box 1 and Box 2) to support a long term vision for core activity that is flexible to local priorities.

4. Support health services to assess their systems of care

There are now health system assessment tools specifically adapted to optimise the primary health care of Indigenous Australians based on the Chronic Care Model.13 Over 200 Aboriginal primary health care services have used such tools (Appendix 2). Many ACCHSs self-audit their performance using clinical audit tools for chronic disease, maternal and child health and other health priorities, and undertake generic health systems assessment as part of continuous quality improvement (CQI).14

Health system assessment and audits of actual practice against best practice standards should be used to guide PHN (and LHN where there is conjoint responsibility) priorities to systematically enhance quality care within all primary care services in PHN boundaries. Barriers to and enablers for systems improvement, and gaps in health service responsiveness to Aboriginal health needs, will be clearer. These include improving systems for follow-up of patients, use of electronic registers and recalls, Aboriginal community engagement and leadership, the commitment of workforce and management, service infrastructure, and staff training and support.14,15

5. Embed quality assurance activity within primary health care services

A commitment to CQI is a key strategy for disease prevention (Appendix 3) and the prevention of avoidable hospitalisations (Appendix 4), and should be a universal feature of primary health care services providing care to Aboriginal and Torres Strait Islander peoples.15

A national Aboriginal and Torres Strait Islander CQI framework supported by the Australian Government will shortly be released to guide jurisdictions to assess and deliver better quality primary health care.16 PHNs should endorse and adapt this framework to coordinate efforts and develop CQI implementation plans. For example, most state and territory affiliates of the National Aboriginal Community Controlled Health Organisation provide support to ACCHSs for CQI activities; and in some jurisdictions (Queensland and the Northern Territory), CQI support programs are well developed.14

PHNs will need to engage with existing programs to identify strategies for and barriers to CQI. Supporting CQI within the network boundary will require regional facilitators, trained staff, the coordinated use of shared electronic medical records and use of local information management systems by all providers (including locums and visiting services), regular monitoring of CQI indicators, performance reporting, and agreements on data use, ownership and reporting.14

6. Expand primary health care performance reporting

All primary health care services within each PHN delivering care to Aboriginal people (and especially in receipt of financial grants or incentives specific to Indigenous Australians) should be required to undertake CQI, and to participate in regional or centralised performance reporting which can be disaggregated by Aboriginality. Primary health care performance should be a core responsibility of quality, safety and risk subcommittees of both PHNs and LHNs.3 Aggregated CQI data at PHN levels can identify health service gaps and areas that need to be improved.16

The Australian Government reporting framework for PHNs will include national, local and organisational performance indicators.17 National indicators for PHNs will include primary and community health indicators such as potentially preventable hospitalisations (these will be sourced from existing datasets such as the National Hospital Morbidity Database) not unlike what is currently reported for LHNs. Potentially preventable hospitalisations are an indirect measure of whether people are receiving adequate primary health care. The disproportionately high rate of illness affecting Aboriginal people and their poorer access to primary health care explains higher potentially preventable hospitalisation rates independent of age, sex and remoteness (Appendix 4). Age-standardised potentially preventable hospitalisation rates within PHN boundaries should be disaggregated by Aboriginality and incorporated as a performance indicator within PHN strategic plans.

The selection of local and organisational performance indicators by PHNs should be guided by the Aboriginal steering committee. Benchmarking PHN progress using Aboriginal and Torres Strait Islander national key performance indicators18 should be considered. National key performance indicators serve as both a CQI tool and performance measure in the provision of primary health care to Indigenous Australians. For example, ACCHSs are required to report on 19 key performance indicators through a standardised portal supported by the Australian Government.7 Organisational performance reporting of PHN activity should quantify the allocation of funds towards Aboriginal programs and contractors and identify whether these are ACCHSs or other services.

7. Align and endorse PHN and LHN strategic plans

Commitment to region-specific Aboriginal primary health care strategic plans should be the goal for both PHN and LHN boards so that actions are informed by both and integrated to avoid cross purposes.3 These linkages might be streamlined in regions where PHNs have been established by LHNs. However, it is unclear how many LHNs have established Aboriginal health subcommittees or effective and formalised Aboriginal community engagement mechanisms to facilitate endorsement of strategic plans.

All PHNs are expected to complete baseline needs assessment and strategies to respond to service gaps.19 If these submissions pertain to the Aboriginal and Torres Strait Islander population, they should be accompanied by evidence of endorsement by the Aboriginal representative bodies in their region.

8. Strengthen the primary health care service model

Many visiting health providers can overburden Aboriginal people in remote communities with overlapping and poorly explained services.20 A core priority for PHNs is to review the coordination of care and improve clinical pathways in all geographic regions. PHNs will need to review the efficiency of current services including generalist and specialist outreach if they are to avoid duplication, foster local or residential health services,21 and sustain local CQI systems.

Specialist outreach should complement local health services through a bottom-up approach integrated with primary health care. Specialist outreach services operating independently of existing primary health care services will need review. Service reforms might mean building hub-and-spoke models involving ACCHSs, supporting regional Aboriginal health networks (Box 1), using telehealth adapted for Aboriginal and Torres Strait Islander settings, renegotiating clinical pathways, empowering local outreach coordinators of hospitals to support primary health care models, substituting workforce tasks through nurse and Aboriginal and Torres Strait Islander health practitioners, rural generalists and physician assistants,22 and reorienting health services towards primary health care (Box 2, Appendix 5).

9. Enhance cultural competence of primary health care services

Strategies to merely increase the awareness of non-Indigenous health staff to Aboriginal cultural protocols are often recommended to reduce Aboriginal health disparities, but may not lead to cultural competence.23 Some staff still struggle with how to make services culturally responsive beyond the posting of Aboriginal artwork.20 The ICDP invested in cultural awareness training of over 6000 general practice staff but change in practice was not universally embraced.8,15

Enhancing the cultural competence of health services within PHN boundaries will require strategies best managed by the Aboriginal steering committee and may include subcontracting ACCHSs and expanding their outreach role, person-centred and family-oriented care, fostering a culturally identified workforce that reflects the patient population and health needs, staff training in cultural safety, performance measures for cultural competence, and future planning.

10. Transition primary health care services to Aboriginal community control

PHNs are to be the health “providers of last resort and their decision to directly provide services should require the approval of the Department of Health”.3 Agreement from local ACCHSs in the region should be required if a PHN opts to directly provide health services to Aboriginal communities rather than make purchasing arrangements with existing Aboriginal services (Box 1). ACCHSs should also be supported to choose their involvement in programs within the PHN boundary.

Coalitions of Aboriginal organisations have advised that future funding on Indigenous health programs be prioritised to ACCHSs being better placed to meet Aboriginal health needs with better returns on investment.24 For example, according to the ICDP evaluation, it was unclear whether Closing the Gap measures (such as financial incentives to general practices) increased the provision of services to Aboriginal people who are “hard to reach” or increased their access to primary health care.9,15 For PHNs, it makes sense to direct Aboriginal health strategies to health services with the desire and potential to provide quality care to Aboriginal patients, which is also more cost-effective.15

The Queensland and Northern Territory governments have commenced processes to transition certain health services in remote areas to Aboriginal community control.25,26 The aim is to reform remote area services from doctor-focused, illness-centred, acute hospital-based primary care services to community-engaged, comprehensive, preventive and responsive systems. Policy frameworks propose staged approaches and capacity building of existing ACCHSs. Strategic plans developed by PHNs should consider transitioning health services and responding to existing transition plans26 to ensure alignment with them.

Conclusion

These proposals offer policy makers and PHNs a framework for health service planning within newly established boundaries, and may inform PHN organisational performance reporting on efforts to close the gap in Aboriginal health disparity.

Australians report that our health system is not sufficiently patient focused. Primary care is reactive and episodic, funding structures support providers and not patients, and there is little accountability for health outcomes.4 Through existing and better targeted additional investments, PHNs can offer Aboriginal and Torres Strait Islander people some hope towards reforming access to and quality of primary health care in their localities, but only if programs and systems can better fit in with community needs. To close the gap, PHNs need to support Aboriginal communities towards greater participation in primary health care, ultimately through the expression of community control.

Box 1 –
Example: collaboration between Medicare Locals and Aboriginal community controlled health services

In 2008, to close the gap in Aboriginal health disparity, the Indigenous Chronic Disease Package funded the Care Coordination and Supplementary Services (CCSS) program. The program supports Aboriginal and Torres Strait Islander patients with complex care needs, by coordinating clinical care and providing supplementary funding for allied health, specialists, transport services and medical aids. Implementation required collaborations between Aboriginal and mainstream health services. In South-East Queensland, the Metro North Brisbane Medicare Local (MNBML) was funded to deliver the CCSS program on behalf of four other Medicare Locals in South-East Queensland. A consortium of ACCHSs — the Institute for Urban Indigenous Health (IUIH) — was subcontracted by the MNBML to implement the program in 2013–14. IUIH employed a manager to oversee the program delivered by 20.5 full-time equivalent care coordinators.

The IUIH reported that subcontracting delivered significantly more services to significantly more Indigenous Australians with complex chronic conditions than any other part of the country: “In 2013–14 IUIH and members [ACCHSs] delivered over 57 000 episodes of care via the CCSS Program. The delivery of intensive case management and access to a comprehensive range of specialist and allied health services and medical aides for this population has avoided costly hospital admissions for Government and significantly improved the health and wellbeing of some of our most vulnerable and unwell patients.”10

Box 2 –
Example: a partnership to reorient acute care to comprehensive primary health care

Clinic services in the very remote Fitzroy Valley in Western Australia are delivered by state government health services (Fitzroy Crossing Hospital and the Kimberley Population Health Unit for community health services). Non-clinical health services are delivered by the Aboriginal community controlled health service (Nindilingarri Cultural Health Services) to a population of 3500 (80% Aboriginal). These services comprise healthy lifestyle programs designed around Aboriginal culture. A formal agreement between the agencies was negotiated in 2006 to form a single governance structure to allocate funding, share an e-health record, and coordinate health promotion, cultural safety, acute inpatient care, primary care and specialist care, and population-based screening. Commonwealth funding supported the development of a shared e-health record for quality improvement and additional staff (through the Healthy for Life and Indigenous Chronic Disease programs), and provided Medicare rebates to patients for primary care services delivered at the hospital clinic (an exemption from section 19(2) of the National Health Insurance Act 1973). Medicare billings were reinvested to support this reorientation under the guidance of the partners.

This reorientation enhanced health promotion programs and was associated with a reversal of the increasing trend in emergency department attendances. In the primary care clinic, there was a substantial increase in the number of patients seen, the number of health checks, the detection of risk factors, the proportion of patients with diabetes having care plans, transport provision, cultural security and follow-up attendances in only 6 years.12

GPs are where the home is

The AMA has called on the Federal Government to consult closely with the nation’s GPs in advancing plans to introduce its Health Care Homes model of primary care.

In its first major response to the Primary Health Care Advisory Group report finalised late last year, the Government has announced it will trial Health Care Homes as a way to improve care for patients with complex and chronic health conditions.

AMA President Professor Brian Owler said the peak medical group welcomed the Government’s acknowledgement of the pivotal position played by GPs in primary care, particularly in the ongoing treatment of patients with chronic disease.

Professor Owler said the Government’s Health Care Home concept reflected many of the principles recommended by the AMA, including voluntary enrolment, the continued use of fee-for-service for routine care, and a focus on patients with complex and chronic conditions.

But he said Health Minister Sussan Ley’s announcement left many critical questions unanswered, particularly the scale of investment the Government would make to support the initiative.

“I think this concept of a Health Care Home is a good one,” Professor Owler said. “Having a stronger bond between patients and a practice or a GP is a good thing, but we need to see how the funding is going to work. The proposals are good, but it needs to come with investment.”

The AMA President said he was particularly concerned that funds were not diverted from elsewhere in the health system to fund the initiative.

He said Australia’s GPs had been the target of repeated funding cuts in recent years, most particularly the current freeze on Medicare rebates, and if the Health Care Home concept was to improve patient care and reduce pressure on public hospitals, “significant new funding is needed”.

Internationally, the term Medical Home is used to refer to a model of primary care that is patient-centred, comprehensive, team-based, coordinated, accessible and focused on quality and safety.

It is envisaged patients would nominate or register with a GP or medical practice as their Medical Home, making it the hub for coordinating and integrating their care among a multidisciplinary team of health professionals.

Releasing the AMA’s Position Statement on the Medical Home earlier this year, Vice President Dr Stephen Parnis said in Australia these attributes were already embodied in general practice.

“The concept of the Medical Home already exists in Australia, to some extent, in the form of a patient’s usual GP,” Dr Parnis said. “If there is to be a formalised Medical Home concept in Australia, it must be general practice. GPs are the only primary health practitioners with the skills and training to provide holistic care for patients.”

The Medical Home concept is seen as a way to improve the care of patients with complex and chronic illnesses, helping them manage their conditions will living in the community rather than needing regular expensive and disruptive hospitalisation.

The Federal Government has made improved primary care of chronically ill patients a priority in order to reduce the pressure on the health budget.

While GPs and hospitals have greatly improved the efficiency and cost-effectiveness of the care they provide, the chronic disease burden has swollen as the population has aged and patients have developed significant co-morbidities.

Dr Parnis said the Medical Home concept had the potential to deliver improved support for GPs in providing well-coordinated and integrated multi-disciplinary care for patients with chronic and complex disease, and it made sense for this to be the focus of Government thinking on adopting the Medical Home idea in Australia.

Evidence suggests patients with a usual GP or Medical Home have better health outcomes, and 93 per cent of Australians have a usual general practice, and 66 per cent have a family doctor.

Earlier this year, the AMA issued a Position Statement in which it backed the concept of a GP-centred Medical Home, as long as it was tailored to local conditions and maintained the fee-for-service remuneration system.

“You can’t just transplant models of health care from other countries without acknowledgement of local conditions and what is already working well,” Dr Parnis said. “Australia needs to build on what works, and ensure that a local version of the Medical Home is well-designed and relevant.”

The AMA said establishing the Medical Home concept in Australia was likely to involve formally linking a patient with their nominated GP or medical practice through registration – a process it said should be voluntary for both patients and doctors.

The Government will appoint a Health Care Home Implementation Advisory Group to help steer the introduction of the scheme.

The AMA Position Statement on the Medical Home can be viewed at: position-statement/ama-position-statement-medical-home

Adrian Rollins

Your season of birth is stamped on your DNA and can affect your risk of allergies

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People born in autumn or winter are more likely to suffer from allergies than people born in spring or summer. Nobody is certain why this is, but there are several theories. These include seasonal variations in sunlight (which could affect vitamin D levels), levels of allergens such as pollen and house dust mite (which vary by season), the timing of the baby’s first chest infection (colds tend to be more common in winter), and maternal diet (price and availability of fruit and vegetables vary by season).

But no matter which of these exposures causes changes to the risk of developing an allergy, until now nobody knew how these early environmental influences were so long lasting.

Our study tested whether epigenetic marks on a person’s DNA could be a mechanism behind these birth season effects. Of course, your genome doesn’t change depending on which season you’re born in, but there are epigenetic marks attached to your DNA that can influence gene expression – the process where specific genes are activated to produce a certain protein. This may result in different responses to immune triggers and hence different susceptibility to diseases.

Unlike DNA, which is inherited from your parents, epigenetic marks can change in response to the environment and allow gene expression to respond to environmental exposures. And they can also be very long-lasting.

Epigenetic imprint

We scanned DNA methylation (one type of epigenetic mark) profiles of 367 people from the Isle of Wight and found, for the first time, that the season in which a person is born leaves an epigenetic print on the genome that is still visible at the age of 18. This discovery means that these marks on the genome could be how season of birth is able to influence the risk of having allergies later in life.

We went on to test whether these DNA methylation differences that varied by season of birth were also associated with allergic disease. We found that two of them appeared to be influencing the risk of allergy in the participants. As well as allergies, other studies have shown that season of birth is associated with a number of things such as height, lifespan, reproductive performance, and the risks of diseases including heart conditions and schizophrenia. It is possible that the birth season-associated DNA methylation that we discovered might also influence these other outcomes but this will need further investigation.

The marks that we found in the DNA samples collected from the 18-year-olds were mostly similar to the epigenetic marks found in a group of Dutch eight-year-olds that we used to validate our findings. But when we looked at another cohort – a group of newborn babies – the marks were not there. This suggests that these DNA methylation changes occur after birth, not during pregnancy.

There’s something about the seasons

We are not advising women to change the timing of their pregnancy, but if we understood exactly what it was about birth season that causes these effects, this could potentially be changed to reduce the risk of allergy in children. For example, if the birth season effect on allergies was found to be driven by sunlight levels experienced by the mother during pregnancy or breastfeeding, then the increased risk of allergies among babies born in autumn and winter might be lessened by giving the expectant or breastfeeding mother vitamin D supplements. You wouldn’t need to time births with the seasons to get the benefits.

Our study reports the first discovery of a mechanism through which birth season could influence disease risk, though we still don’t know exactly which seasonal stimuli cause these effects. Future studies are needed to pinpoint these, as well as to investigate the relationship between DNA methylation and allergic disease, and what other environmental exposures have an effect.

With the considerable burden allergic disease places not only on individual sufferers but also on society, any step towards reducing allergy is a step in the right direction.

Gabrielle A Lockett, Postdoctoral research associate, University of Southampton and John W Holloway, , University of Southampton

This article was originally published on The Conversation. Read the original article.

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New recommendations for Hepatitis C treatment

New recommendations have been released for the management of hepatitis C virus (HCV) infection in a consensus statement.

The statement was drawn up by Gastroenterological Society of Australia, the Australasian Society of Infectious Diseases, the Australasian Hepatology Association, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Hepatitis Australia and the Royal Australian College of General Practitioners.

A summary, published in the Medical Journal of Australia, says that the recommendations for Hepatitis C treatment were drawn up in the wake of the new direct-acting antiviral therapies that were added to the Pharmaceutical Benefits Scheme earlier this month.

“The introduction of DAA therapies for HCV that are highly effective and well tolerated is a major medical advance,” said Professor Alexander Thompson, director of gastroenterology at St Vincent’s Hospital in Melbourne.

“All Australians living with HCV should now be considered for antiviral therapy.”

Recommendations in the consensus statement include:

All individuals with a risk factor for HCV infection should be tested.
Annual HCV serological testing is recommended for seronegative individuals with risk factors for HCV transmission.
People with confirmed HCV infection should be tested for HCV genotype (Gt).
All concomitant medications should be reviewed before starting treatment, using the University of Liverpool’s Hepatitis Drug Interactions website.
The use of any DAA regimen during pregnancy is not recommended.
People who are not cured by a first-line interferon-free treatment regimen should be referred to a specialist centre.
All people with decompensated liver disease, extra-hepatic manifestations of HCV, HCV–HIV or HCV–HBV co-infection, renal impairment or acute HCV infection, as well as people who have had a liver transplant should be referred for management by a specialist who is experienced in the relevant areas.
All people living with HCV infection should have a liver fibrosis assessment before treatment to evaluate for the presence of cirrhosis.
People with no cirrhosis can be treated by general practitioners working in consultation with specialists.

Read the full recommendations on the Gastroenterological Society of Australia’s website.

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