review of chronic care services in northern queensland · this review in 2017 nqphn engaged kp...

REVIEW OF CHRONIC CARE SERVICES IN NORTHERN

QUEENSLAND

Prepared for Northern Queensland Primary Health Network

December 2017

[Month Year]

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Acknowledgments and Disclaimer

KP Health acknowledges and respects the Traditional Owners and Aboriginal and Torres

Strait Islander Elders past and present. KP Health also acknowledges and thanks all

stakeholders, service providers and community members who provided time and

feedback as part of the review process.

This report has been prepared in response to a contract between KP Health and the

Northern Queensland Primary Health Network (NQPHN) and the specific outputs

required therein.

The findings in this report have been formed based on information provided by the

NQPHN and their nominated stakeholders, cited references and the methods described

in the report. KP Health has relied on that information being accurate and up to date.

Reported results from stakeholders consulted reflect a perception of the approved

representative sample. Any projection to the wider stakeholder group is subject to a level

of bias in the method of sample selection.

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Glossary and acronyms

Acronym

Name

ABS Australian Bureau of Statistics

ACCHOs Aboriginal Community Controlled Health Organisations

ACRRM Australasian College of Rural and Remote Medicine

AHP Allied health professionals

AHPRA Australian Health Practitioner Regulation Agency

AICCHS Aboriginal and Islander Community Controlled Health Services

AIHW Australian Institute of Health and Welfare

AMS Aboriginal Medical Service

ASGC-RA Australian Standard Geographical Classification - Remoteness Area

ASR Age standardised rate

BMI Body mass index

CHF Chronic Heart Failure

CHHHS Cairns and Hinterland Hospital and Health Service

COAG Council of Australian Governments

Commissioning A dynamic process of planning, procuring, monitoring and evaluating

initiatives to meet the health and wellbeing needs of local populations.

COPD Chronic Obstructive Pulmonary Disease

DoH Commonwealth Department of Health

EP Exercise Physiologist

FIFO Fly-in-fly-out

GP General Practitioner

HFPEF Heart failure with preserved ejection fraction

HHS Hospital and Health Service

ITC Integrated Team Care (formerly Care Coordination and Supplementary

Services)

LGA Local government areas

LVSD Left ventricular systolic dysfunction

MBS Medicare Benefits Scheme

MHHS Mackay Hospital and Health Service

MMM Modified Monash Model

MOICDP Medical Outreach Chronic Disease Program

NGO Non-Government Organisation

NQPHN Northern Queensland Primary Health Network

Outcome The desired end result of a service, project or program that results in a

benefit. Outcomes are achieved through the utilisation of the outputs.

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Acronym

Name

Output Any measurable, tangible, verifiable result of intermediate activities

produced (e.g. products, services, business or management practices). Outputs are well defined, specific and measurable

PBS Pharmaceutical Benefits Schedule

PHN Primary Health Network

Physio Physiotherapist

PIP Practice Incentive Payment

PPH Potentially preventable hospitalisations

Procurement The process/function of obtaining goods and services through contractual

arrangements.

RDAQ Rural Doctors Association of Queensland

RFDS Royal Flying Doctor Service

RHOF Rural Health Outreach Fund

QAIHC Queensland Aboriginal and Islander Health Council

SARRAH Services for Australian Rural and Remote Allied Health

Stakeholder An individual or entity that has an interest in, or may be affected by, the

organisations activities, programs and/or outcomes. This includes but is not limited to service providers, consumers, community members.

Stepped care approach

Service delivery involves a spectrum of interventions to meet different health needs and the model of care allows for the individual to receive the

level of support and intervention they require when they require it.

TCHHS Torres and Cape Hospital and Health Service

THHS Townsville Hospital and Health Service

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Contents

Acknowledgments and Disclaimer ..................................................................................... 2

Glossary and acronyms .................................................................................................... 3

Executive Summary .......................................................................................................... 7

Priorities for chronic disease commissioning .................................................................. 7

Commissioning allied health care, not allied health services............................................ 8

Recommendations ....................................................................................................... 10

Introduction .................................................................................................................... 11

This review .................................................................................................................. 11

Review methodology ................................................................................................... 12

Limitations of the review .............................................................................................. 13

Chronic disease burden and priority populations .............................................................. 15

Health needs of people in rural and remote Australia .................................................... 15

Health needs of Aboriginal and Torres Strait Islander Australians .................................. 17

The impact of low socio-economic status on health ....................................................... 19

NQPHN’s chronic disease priorities .............................................................................. 20

The role of the allied health workforce in improving chronic disease outcomes .................. 23

Workforce challenges in the delivery of allied health care ............................................. 26

Other health workforce gaps ........................................................................................ 28

Allied health service gaps in northern Queensland ........................................................ 30

Recent initiatives to build the rural and remote allied health workforce .......................... 31

Stakeholder views on the current delivery of allied health care ......................................... 34

Competitive not collaborative service arrangements ..................................................... 34

Fragmented and poorly coordinated chronic care services ............................................ 36

A complex system to navigate ...................................................................................... 37

Problems with workforce recruitment, retention and capability-building .......................... 37

Barriers to accessing services, poor cultural awareness ............................................... 39

Poor role delineation, governance, monitoring and oversight ......................................... 42

Improving models of allied health care ............................................................................. 44

Allied health models of care - what the evidence says .................................................. 44

Co-design results - stepped models of allied health care ............................................... 49

NQPHN framework and roadmap for commissioning allied health care ............................. 56

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Appendix 1: National Strategic Framework for Chronic Conditions .................................... 60

Appendix 2: Allied health service map for priority chronic conditions ................................. 62

Service map methods .................................................................................................. 62

Appendix 3: Findings from consultation with stakeholders ................................................ 69

Strengths of the chronic care service system ................................................................ 69

Identified Chronic Care Service System Needs ............................................................. 76

Challenges and opportunities with commissioning ........................................................ 79

Summary .................................................................................................................... 80

Figures

Figure 1: GPs per 100,000 population by state and remoteness area ............................... 29

Figure 2: NQPHN stepped model of allied health care ...................................................... 50

Tables

Table 1: Self-reported chronic disease, 2014-15, National Health Survey ......................... 16

Table 2: Self-reported health risk factors, 2014-15, National Health Survey ...................... 17

Table 3: Potentially preventable hospitalisations for diabetes complications, NQPHN ........ 21

Table 4: Potentially preventable hospitalisations for COPD, NQPHN ................................ 21

Table 5: Potentially preventable hospitalisations for CHF, NQPHN ................................... 22

Table 6: Summary findings, allied health service mapping, northern Queensland .............. 30

Table 7: Modified tiered outreach model .......................................................................... 51

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Executive Summary

The Northern Queensland Primary Health Network (NQPHN) is one of 31 primary health

care organisations established nationally to commission services to meet regional health

care needs.

NQPHN is moving from a procurement-based to a commissioning-based organisation. This

is part of a national PHN reform agenda designed to increase the efficiency and

effectiveness of services for patients, especially those at risk of poor health outcomes; and

improve the coordination of care to ensure patients receive the right care in the right place

at the right time. Commissioning moves beyond the current system of simple service

contracting and purchasing to a focus on health outcomes. This gives commissioned

providers flexibility in how they choose to deliver services, as long as they achieve the

health outcomes they are contracted to deliver.

This review

In 2017 NQPHN engaged KP Health to review allied health-provided chronic care services

in rural and remote areas of Northern Queensland and contribute to the evidence base to

inform chronic care commissioning and reform in the NQPHN region.

To complete this review, we adopted a mixed-methods approach that included triangulating

data from a review of the relevant literature and policy documents, service mapping based

on available service system and administrative data, and semi-structured interviews and co-

design workshops with key stakeholders.

Priorities for chronic disease commissioning

We identified three Northern Queensland chronic disease priority areas for commissioning

chronic disease-specific services - diabetes complications, chronic heart failure (CHF) and

chronic obstructive pulmonary disease (COPD). These chronic disease priorities are

identified in the NQPHN comprehensive needs assessment as contributing to large and

increasing potentially preventable hospitalisations in Northern Queensland and are highly

prevalent in the NQPHN catchment*.

Within these priority areas, we identified three priority population groups - rural communities,

people from low socio-economic backgrounds and Aboriginal and Torres Strait Islander

peoples – who are disproportionately affected by adverse health outcomes associated with

these chronic diseases.

Current delivery of allied health services

Allied health care is essential to improving health outcomes for people with chronic

diseases. Historically, procurement of allied health services in rural communities has been

* We note, however, that this does not preclude other priority areas such as mental health and Indigenous chronic

disease which are currently commissioned from different funding sources.

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an important mechanism to provide more allied health care in communities that otherwise

are unable to attract and retain permanent services. Whilst procurement of these services

has increased rural allied health service provision, allied health care delivery is episodic,

with communities left with no provision of the service locally when the provider is not

physically present in the community.

Stakeholders report current models of allied health care are fragmented, poorly coordinated,

episodic in nature and lack service continuity, particularly for these chronic disease priorities

and within these priority population groups. For example, one rural community reported they

receive visiting diabetes educator services from two different organisations. Both

organisations deliver services once every six weeks. Because the providers are funded by

different organisations they do not share their visiting schedule. As a result, they arrive in

the community within a day of each other, rather than providing the community with a

diabetes educator service every three weeks. Further, they did not know the other provider

was delivering care in the same community, and therefore do not share information,

communicate with one another or plan their services accordingly.

Rectifying this situation is challenging at present because service providers across the

NQPHN catchment describe a culture of uncertainty and competition for scarce resources.

This creates a disincentive for different provider organisations to work together to deliver

better care.

Commissioning allied health care, not allied health services

Commissioning provides NQPHN with a mechanism to fundamentally change the way allied

health care is delivered, particularly in rural areas. NQPHN can, through commissioning,

reorient allied health service delivery to improve continuity of allied health care and leverage

the capacity of the generalist workforce to deliver services.

Stepped models of allied health care

This review found generalist providers within local communities have the capacity and

willingness to deliver low intensity allied health care. Personal carers, Aboriginal health

workers and nurses can, with the support of allied health specialists, provide less complex

components of a patient’s allied health care needs and appropriately refer more complex

patients to visiting allied health specialist providers, making better use of the visiting

providers expertise and available time. Where generalist providers identify a patient with

urgent care needs, these can be referred to the visiting specialist allied health provider

(regardless of whether they are physically located in the community at the time of the

referral) to ensure timely patient triage, assessment and management. These models are

evidence based, supported by the peer reviewed literature, and significantly improve service

continuity.

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A podiatry stepped care example

The current situation – a visiting podiatrist provides a clinic in a rural community once

every 6 weeks. The podiatrist reviews any patients the local clinicians have referred. As a

result the podiatrist may perform tasks such as trimming toenails (a low complexity task) and

patients with acute foot care needs cannot be reviewed in a timely fashion. There are often

waiting times of many months to see the visiting podiatrist. When the podiatrist is not

physically present in the community, the community has no service.

A new, improved stepped model – a visiting podiatrist provides a clinic in a rural

community once every 6 weeks. The podiatrist supports local generalist health workers

between visits. Local trained generalist health workers (personal carers, Aboriginal health

workers, nursing personnel) who already care for people with at-risk feet provide foot care

(trimming nails, applying heel balm, paring calluses) as part of their usual role. If the

generalist health worker reviews a patient with an at-risk foot (e.g. an emerging foot ulcer)

they can contact the podiatrist for advice and support. They may take a photograph of the

foot with their smartphone and forward this to the podiatrist. The patient can be escalated to

be urgently reviewed by the podiatrist next visit. If the problem is more urgent, the podiatrist

can triage the patient to more urgent specialist care.

The role of technology in stepped models of allied health care

Technology therefore has an important role to play in linking the visiting specialist allied

health providers with the local members of the care team. Telehealth, videoconferencing

and smart phones can enable the local provider to share clinical images with the specialist

allied health provider, to consult with the allied health provider and to facilitate collaboration

between the patient and members of the patient’s care team.

Education and training to support delivery of stepped models of allied health care

Education, training and professional development for the generalist workforce is essential to

develop the capability of the generalist workforce. Training is already available for many

relevant aspects of allied health care (e.g. foot care to support podiatry service delivery,

fitness industry professional courses to support exercise physiology and physiotherapy

service delivery).

The role of allied health assistants

Northern Queensland is developing a Northern Queensland allied health assistant

workforce. Unlike the generalist workforce, who are already employed and have existing

therapeutic relationships with patients, an allied health assistant workforce will be an

additional member of the care team, the sources of funding for which are yet to be

determined.

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Recommendations

The following recommendations are proposed for NQPHN commissioning of chronic disease

allied health services:

Recommendations

1. That, in its guidance to potential commissioned providers, NQPHN requires potential

commissioned providers to:

a. indicate which chronic disease priorities their proposed service solution

addresses (including but not necessarily limited to diabetes complications, COPD

and heart failure);

b. describe how their proposed service solution will focus on the specific allied

health care needs of rural, low SES and Aboriginal and Torres Strait Islander

priority population groups.

2. That NQPHN commissions a stepped model of allied health care that requires


a. deliver continuity of allied health care by integrating visiting allied health services

with local generalist providers;

b. work with local communities to identify and build the capacity of local generalist

providers to deliver continuity of allied health care;

c. indicate how the commissioned provider will utilise technology to support

continuity of allied health care; and

d. describe how the proposed stepped allied health services will be governed,

including how risk will be managed.

3. That NQPHN requires contracted agencies to monitor and report on patient outcomes,

service priorities and opportunities to further develop services and improve access.

4. That NQPHN requires contracted agencies to establish protocols with other service

providers with a presence in the community to update patient records and transfer

information.

In implementing these recommendations through commissioning al lied health care, NQPHN

will demonstrate its health services leadership role in reorienting the health service system

to provide coordinated, accessible and more efficient allied health care that better meets the

need of consumers. As a commissioning entity, one of the ongoing roles of NQPHN will be

facilitating collaboration between the acute, primary and community sectors to achieving its

vision that Northern Queenslanders live happier, healthier, longer lives.

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Introduction

Northern Queensland Primary Health Network (NQPHN) has engaged KP Health to review

its Chronic Care Services in rural and remote areas of Northern Queensland.

The Northern Queensland Primary Health Network (NQPHN) is one of 31 Primary Health

Networks (PHNs) established nationally. The objectives of PHNs are to:

increase the efficiency and effectiveness of medical services for patients, especially

those at risk of poor health outcomes; and

improve coordination of care to ensure patients receive the right care in the right

place at the right time.

The Commonwealth has set six priority areas for PHN attention:

Aboriginal and Torres Strait Islander health;

mental health;

population health;

health workforce;

eHealth; and

aged care.

This review

NQPHN engaged KP Health to conduct this review of chronic care services in rural and

remote areas of Northern Queensland. The objectives of the review are to:

inform the re-commissioning of the chronic care allied health services that NQPHN

currently funds;

develop an evidence-base to inform wider chronic care service re-structuring and

reform, including rural allied health workforce reform;

facilitate the partnerships that will enable these changes; and

propose a roadmap for chronic care reforms to address service gaps and improve

resident access.

This is the first review of its kind as it considers the existing chronic care services funded by

NQPHN within the broader context of the chronic care service system in the NQPHN

catchment.

The review draws on a combination of qualitative and quantitative data analysis to achieve

the objectives outlined above. In line with the NQPHN quadruple aim outcomes, this report

describes opportunities to improve the delivery of consumer-driven, safe, sustainable, high-

quality chronic care services.

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Review methodology

To conduct the review we implemented a staged, mixed-methods approach, combining

evidence review and analysis, service mapping and data analysis and stakeholder

consultation. The findings from these activities informed co-design of allied health models of

care that can be commissioned by NQPHN.

Evidence review and analysis

We reviewed academic literature and grey literature to find studies, reviews and reports on

the delivery of allied health care, including but not limited to allied health service models in

rural and remote areas.

For academic literature, we searched the CINAHL, Cochrane Library, Medline, PubMed and

Google Scholar databases. Searches were limited to 2007 to 2017 calendar years, but

earlier publications were accessed where perusal of reference lists indicated they may be of

value*.

The following Australian sites were searched for grey literature.

Australian Government Department of Health:

www.australia.gov.au/directories/australia/health

Australian Institute of Health and Welfare (AIHW): www.aihw.gov.au/

Health Workforce Queensland: https://www.healthworkforce.com.au/

Service mapping

We established a service baseline informed by stakeholder consultation and review of

relevant service system and administrative data.

We analysed relevant service system and administrative data from the Australian Bureau of

Statistics (ABS), AIHW, Queensland Health, Commonwealth agencies and NQPHN to

identify the disease burden affecting the NQPHN catchment and analyse the utilisation and

geographical spread of existing chronic care services.

Stakeholder consultation

We consulted with stakeholders to explore their views regarding chronic disease priorities in

the NQPHN catchment, adequacy of allied health care to meet patient needs in these

priority areas, and opportunities to improve the quality, efficiency and coordination of allied

health care in the catchment.

We used a snowball sampling technique to identify stakeholders for our preliminary

consultation. This involved us consulting first with key stakeholders identified by NQPHN.

* MESH Terms used were: “allied health occupations”, “podiatry”, “nutritionists”, “rural health”, "delivery of health

care, integrated", “chronic disease”. Additional Key Words included: “allied health”, “diabetes educator*”, “physiotherap*”, “dietitian*”, “dietician*”, “social worker*”, “occupational therap*”, “rural”, “complex conditions” and “chronic care needs”.

http://www.australia.gov.au/directories/australia/health

http://www.aihw.gov.au/

https://www.healthworkforce.com.au/

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Each stakeholder we consulted with identified additional stakeholders with whom we

consulted. We continued this process until stakeholders no longer nominated additional

people with whom we should consult.

Using this method, we consulted with 210 individuals as part of our consultation process: 45

general practice personnel, 37 consumers, 20 service coordinators / managers, 13 Chief

Executive Officers, 12 allied health professional clinical leads, 10 additional allied health

professionals, 44 other health professionals, 14 health program managers, 10 clinical

executives and five other executive managers. We conducted semi-structured interviews,

primarily as face to face interviews but some interviews were conducted by telephone,

according to stakeholder preference. We continued consulting with stakeholders until

content saturation was achieved.

Service co-design

The findings from our evidence review, service mapping and stakeholder consultation were

synthesised into draft models of allied health care for testing and refining.

There are different methodologies that can be applied to co-designing health services. We

applied a participatory action research (PAR) methodology to our co-design. PAR is an

iterative approach to service co-design that is based on a series of action cycles. The

learnings from each cycle inform the direction of the next cycle. While reviewers know the

general direction of the service model and draft service models for the first action cycle, the

method allows the draft service models to be flexible and to be adapted depending on the

outcomes of each cycle.

We conducted six co-design workshops (cycles) in total - in Charters Towers, Ayr,

Cooktown, Mackay, Cairns and Townsville. Provision was made for people in other areas to

participate via telephone or videoconference, to travel and participate in person or to provide

written submissions. Co-design workshops were attended by consumers and clinicians who

together described current challenges in allied health service provision for chronic disease

and proposed solutions to improve the quality of services.

Chronic Care Roadmap

We synthesised the findings from each review activity and analysed these thematically to

develop a ‘roadmap’ for chronic care reforms designed to address gaps and improve equity

of access through service recommissioning. This roadmap is consistent with the national

Chronic Conditions Strategic Framework, described at Appendix 1.

Limitations of the review

This review provides a baseline service map and overview of stakeholder feedback at a time

of considerable transition and reform. There is potential bias in some of the views

represented here. Although the sample sizes are high for a review of this nature, the

stakeholder views reflected here cannot be taken as representative of the region. Further, at

the time of conducting this review, there were several other reviews contracted by NQPHN

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underway which meant some stakeholders had competing demands and / or consultation

fatigue. This had an adverse impact on levels of engagement in some cases.

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Chronic disease burden and priority populations

The objectives of NQPHN have been established by the Australian government as:

to increase the efficiency and effectiveness of medical services for patients -

particularly those at risk of poor health outcomes; and

to improve the coordination of care to ensure patients receive the right care in the

right place at the right time.

There are three priority population groups identified in the NQPHN comprehensive needs

assessment that are disproportionately affected by adverse health outcomes associated

with chronic diseases - rural and remote communities, people from low socio-economic

backgrounds and Aboriginal and Torres Strait Islander peoples.

Health needs of people in rural and remote Australia

Australians living in rural and remote areas tend to have a lower life expectancy, higher

rates of disease and injury, and poorer access to and use of health services than people

living in major cities1.

Poorer health outcomes in rural and remote areas may reflect a range of social and other

factors that are detrimental to health, including a level of disadvantage related to

educational and employment opportunities, income, and access to health services. People

living in rural and remote areas may face more occupational and physical risks, for example,

from farming or mining work and transport-related accidents, and experience higher rates of

other risk factors associated with poorer health, such as tobacco smoking and alcohol

misuse.

People living in rural and remote areas also have2:

mortality rates 1.4 times as high as people living in major cities;

coronary heart disease mortality rates were between 1.2 and 1.5 times as high in

rural and remote areas as in major cities;

in rural and remote areas, the rate of dying due to a land transport accident was

more than 4 times as high as in major cities; and

1 The term 'rural and remote' encompasses all areas outside Australia's Major cities. Using the Australian Standard Geographical Classification System, these areas are classified as Inner regional, Outer regional, Remote or Very remote. In many instances, the term 'rural and remote' is used interchangeably with the classification terms 'regional and remote. In 2013, 29% of the Australian population lived in rural and remote areas: 18% in Inner regional areas, 8.9% in Outer regional areas, 1.4% in Remote areas and 0.9% in Very remote areas.

2 Australian Bureau of Statistics. Australian Health Survey, 2014/15

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in rural and remote areas, death rates due to diabetes were between 2.5 and 4 times

as high, and, for suicide, between 1.8 and 2.2 times as high as in major cities.

Disease prevalence is generally higher in rural and remote areas of Australia than in major

cities. Based on self-reported data from the 2014-15 National Health Survey (NHS),

compared with people living in major cities, people living in rural and remote areas of

Australia had higher rates of most chronic diseases3 (Table 1).

Table 1: Self-reported chronic disease, 2014-15, National Health Survey

Disease type Major cities Inner regional Outer regional /

remote

Arthritis 14% 20% 18%

Back pain and problems 16% 18% 16%

Asthma 10% 12% 12%

COPD 2.4% 3.4% 2.7%

Blindness 0.5% 0.9% 0.8%

Deafness 9.8% 15% 14%

Diabetes 4.7% 6.0% 6.7%

CVD 4.7% 6.7% 5.8%

Cancer 1.6% 1.7% 1.8%

Mental health problems 17% 19% 19%

People living in rural and remote areas generally also have higher rates of health risk

factors4, including smoking, level of physical activity and alcohol consumption.

Access to primary health care services is one of the key determinants of service success

and sustainability. Poor access, characterized as a barrier to seeking primary health care at

times of need, is the most important factor distinguishing rural from urban health service

utilization behaviour5. Principles of access underpin discussions of the person-centred

3 '%' represents prevalence of chronic diseases in each region (excluding Very remote areas of Australia); Proportions are not age-standardised, and in some instances higher prevalence may reflect the older age profiles in Inner regional and Outer regional/Remote areas;'COPD' refers to chronic obstructive pulmonary disease; 'Blindness' includes partial and complete blindness; 'CVD' refers to heart, stroke and vascular disease. 4 '%' represents prevalence of risk factor in each region (excluding Very remote areas of Australia); 'Proportions' are not age-standardised and, in some instances, higher prevalence may reflect the older age profiles in Inner regional and Outer regional/Remote areas. 5 Ward B, Humphreys J, McGrail M, Wakerman J, and Chisholm M. 2015. Which dimensions of access are most

important when rural residents decide to visit a general practitioner for non-emergency care? Australian Health Review 39: 121-126

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medical home, integrated care, and comprehensive primary health care. They also play a

key role in reform documents6 (Table 1).

Table 2: Self-reported health risk factors, 2014-15, National Health Survey

Health risk factors

Major cities

Inner regional

Outer regional/ Remote

Current daily smoker 13% 17% 21%

Overweight or obese 61% 69% 69%

No/low levels of exercise 64% 70% 72%

Exceed lifetime alcohol risk guideline

16% 18% 23%

High blood pressure 22% 27% 24%

Health needs of Aboriginal and Torres Strait Islander Australians

The health of Aboriginal and Torres Strait Islander Australians is improving on a number of

measures, including significant declines in infant and child mortality and decreases in

avoidable mortality related to cardiovascular and kidney diseases. Despite these

improvements, significant disparities persist between Indigenous and non-Indigenous

Australians. Indigenous Australians continue to have lower life expectancy, higher rates of

chronic and preventable illnesses, poorer self-reported health, and a higher likelihood of

being hospitalised than non-Indigenous Australians7.

There are many dimensions to the poorer health status of Indigenous Australians compared

with other Australians and a complex range of factors are behind these differences. These

include8:

differences in the social determinants of health, including lower levels of education,

employment, income and poorer quality housing, on average, compared with non-

Indigenous Australians;

differences in behavioural and biomedical risk factors such as higher rates of

smoking and risky alcohol consumption, lack of exercise, and higher rates of high

blood pressure for Indigenous Australians; and

6 National Primary Health Care Strategic Framework 2013 and National Strategic Framework for Rural and Remote Health Commonwealth of Australia 2012 Availability: http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/EBD8D28B517296A3CA2579FF000350C6/$File/NationalStrategicFramework.pdf

7 AIHW (Australian Institute of Health and Welfare) 2015a. Aboriginal and Torres Strait Islander Health Performance Framework 2014 report: detailed analyses. Cat. no. IHW 167. Canberra: AIHW. 8 AIHW 2015b. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples: 2015. Cat. no. IHW 147. Canberra: AIHW.

http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/EBD8D28B517296A3CA2579FF000350C6/$File/NationalStrategicFramework.pdf

http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/EBD8D28B517296A3CA2579FF000350C6/$File/NationalStrategicFramework.pdf

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the greater difficulty that Indigenous people have in accessing affordable and

culturally appropriate health services that are in close proximity.

Life expectancy at birth is a measure of how long a newborn person is expected to live, on

average, given the currently observed pattern of mortality in the population. Indigenous

Australians have a life expectancy presently of around 10 years less than non-Indigenous

Australians9.

The main broad causes of deaths among Indigenous Australians are cardiovascular disease

(25%); cancer (neoplasms) (20%); external causes (including suicide and transport

accidents) (15%); endocrine, metabolic and nutritional disorders (including diabetes) (8.9%);

and respiratory diseases (7.9%). Compared with non-Indigenous Australians, cardiovascular

diseases and cancer represented a smaller proportion of deaths, and external causes and

endocrine, metabolic and nutritional disorders represented a larger proportion of deaths,

among Indigenous Australians10.

For males, the largest contributors to the life expectancy gap are cardiovascular diseases

(2.9 years), external causes (or injuries) (1.9 years) and cancer (neoplasms) (1.5 years). For

females, the largest contributors are also cardiovascular diseases (2.7 years), cancer (1.6

years) and external causes (1.3 years)11.

The mortality rate for young children is also a key indicator of the general health of a

population. Indigenous child mortality has been declining steadily over time. Between 1998

and 2014, there was a significant decline in Indigenous child mortality rates (by 33%) and

narrowing of the gap (by 34%) with non-Indigenous child mortality12.

Self-assessed rating of health is a widely used measure of overall health status. The most

recent data are from the 2012-13 Australian Aboriginal and Torres Strait Islander Health

Survey (AATSIHS) report that13:

nearly 4 in 10 (39%) Indigenous Australians aged 15 and over reported their health

status as 'excellent' or 'very good' in 2012-13 - a decrease from 44% in 2008 and

43% in 2004-05;

a further 37% reported their health as 'good, and 24% as 'fair' or 'poor' in 2012-13;

adjusting for differences in age structure, 29% of Indigenous Australians rated their

health as 'fair' or 'poor', which was more than double the non-Indigenous rate of 14%;

9 ABS (Australian Bureau of Statistics) 2013a. Life tables for Aboriginal and Torres Strait Islander Australians, 2010-2012. ABS cat. no. 3302.0.55.003. Canberra: ABS. 10 Ibid 11 Zhao Y, Wright J, Begg S & Guthridge S 2013. Decomposing Indigenous life expectancy gap by risk factors: a life table analysis. Population Health Metrics 11:1-9. 12 AIHW (Australian Institute of Health and Welfare) 2015a. Aboriginal and Torres Strait Islander Health Performance Framework 2014 report: detailed analyses. Cat. no. IHW 167. Canberra: AIHW. 13 2012-13 Australian Aboriginal and Torres Strait Islander Health Survey

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the proportion of Indigenous Australians reporting their health status as 'fair' or 'poor'

was lowest in very remote areas (16%).

In 2012-13, two-thirds (67%) of Indigenous people reported at least one chronic health

condition, with 33% reporting three or more. The proportion of Indigenous people reporting

at least one health condition was similar to that of non-Indigenous people14. Overall, the

most common conditions reported by Indigenous Australians (excluding mental health) were

eye diseases and vision problems (33%), respiratory diseases (31%) and musculoskeletal

diseases (20%)15.

Many deaths occurring in Aboriginal and Torres Strait Islander Australians are considered

potentially avoidable. 'Potentially avoidable deaths' refer to deaths from conditions that

could have been avoided, given timely and effective health care. Rates of potentially

avoidable deaths in a population represent the underlying population health, as well as

health-service use and the accessibility and effectiveness of the health system. In the 5-year

period 2009 to 2013, approximately 6,000 deaths (or 61% of all deaths) of Indigenous

Australians aged 0-74 were classified as potentially avoidable deaths (compared with 51%

of all deaths of non-Indigenous Australians in that age group). After adjusting for differences

in age structure, in the 2009-2013 period the mortality rate for Indigenous Australians who

died from all potentially avoidable causes was more than 3 times the rate for non-Indigenous

Australians (351 and 110 deaths per 100,000 population, respectively)16 17.

There was a 10% decline in the potentially avoidable death rate for Indigenous Australians

in the 2009-2013 period compared with the previous 5-year period of 2003-2007. However,

in the same period the potentially avoidable death rate also declined for the non-Indigenous

population18.

The impact of low socio-economic status on health

There are various material and psychosocial reasons why people living in disadvantaged

areas experience poorer health. Low income can negatively impact housing standards or

reduce access to medical services; low educational attainment can affect access to

information about health services and health risk prevention; and the lack of financial

security may create chronic stress which can negatively impact on physical as well as

mental wellbeing19.

14 Ibid 15 AIHW 2015b. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples: 2015. Cat. no. IHW 147. Canberra: AIHW. 16 SCRGSP 2016. Report on government services 2016. Vol. E, Health. Canberra: Productivity Commission. 17 SCRGSP (Steering Committee for the Review of Government Service Provision) 2014. Overcoming Indigenous disadvantage: key indicators 2014. Canberra: Productivity Commission. 18 SCRGSP 2016. Report on government services 2016. Vol. E, Health. Canberra: Productivity Commission.

19 Australian Bureau of Statistics 2010. Australian Social Trends. Cat 4.102.0. Canberra

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There is also a distinct, step-wise socioeconomic gradient evident in total avoidable

hospitalisation rates in Australia, with each increase in disadvantage accompanied by an

increase in admissions from these conditions. Overall, people in the most disadvantaged

areas of Queensland had 45% more hospitalisations than those in the least disadvantaged

areas20.

The National Primary Health Care Strategic Framework (2013) acknowledged that the social

determinants of health strongly influence the health of individuals and communities, which

highlights the importance for commissioning bodies and commissioned providers to facilitate

access to comprehensive care for people with low socio-economic status and to minimise

out-of-pocket costs to this priority group wherever possible21.

NQPHN’s chronic disease priorities

In its comprehensive needs assessment, NQPHN identifies those chronic diseases that

disproportionately affect the population of Northern Queensland, lead to substantial

morbidity and mortality, and contribute to high rates of potentially preventable

hospitalisations. Among these, diabetes complications, chronic heart failure (CHF) and

chronic obstructive pulmonary disease (COPD) contribute substantially to the large

potentially preventable hospitalisations burden in Northern Queensland, are highly prevalent

in the NQPHN catchment* and are amenable to improved outcomes through the provision of

high quality allied health care.

Diabetes complications

Diabetes is a leading cause of morbidity and mortality in Australia. Diabetes is estimated to

cost the Australian economy at least $14 billion annually. This will rise with the increasing

prevalence of the condition, which is expected to double in the next 20 years 22.

In 2015/16 in the NQPHN catchment the age standardised rate (ASR) of 234 (per 100,000

persons) of potentially preventable hospitalisations (PPH) for diabetes complications was

significantly higher than Australia as a whole (166 ASR) and the two Brisbane and the Gold

Coast PHNs (175-199 ASR), but similar to Darling Downs West Moreton and Central

Queensland Wide Bay Sunshine Coast PHNs (222-234 ASR) and substantially lower than

Western Queensland PHN (430 ASR)23.

20 Page A, Ambrose S, Glover J, Hetzel D. (2007) Atlas of Avoidable Hospitalisations in Australia: ambulatory

care-sensitive conditions. Adelaide: PHIDU, University of Adelaide. 21 Australian Government 2013. National Primary Health Care Strategic Framework. Standing Committee on

Health: 6.

* We note, however, that this does not preclude other priority areas such as mental health and Indigenous chronic

disease which are currently commissioned from different funding sources. 22 IDF Atlas – 6th Edition, 2014

23 AIHW, Potentially preventable hospitalisations, Canberra 2017

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Data for PPH for diabetes complications for NQPHN show that in 2015/16, 1645 residents

were admitted for an average of 4.6 days for management of diabetes complications.

Overall there were 7,634 potentially preventable bed days linked to this disease (Table 3).

Table 3: Potentially preventable hospitalisations for diabetes complications, NQPHN

Diabetes Complications

ASR PPH / 100000 Cases Bed days

2013-14 229 1568 7581

2014-15 268 1860 8426

2015-16 234 1645 7634

People with diabetes have an increased risk of developing a number of serious health

problems. Consistently high blood glucose levels can lead to serious diseases affecting the

heart and blood vessels, eyes, kidneys, nerves and teeth. In addition, people with diabetes

also have a higher risk of developing infections. In Australia diabetes is a leading cause of

cardiovascular disease, blindness, kidney failure, and lower limb amputation.

Chronic obstructive pulmonary disease (COPD)

Over 310,000 Australians aged over 55 years have COPD. It is the second commonest

cause of avoidable hospital admissions in Australia and in 2012 was the fifth leading cause

of death in Australia, accounting for 4% of all deaths24.

In 2015/16 in the NQPHN catchment the age standardised rate of 319 (per 100,000

persons) of potentially preventable hospitalisations for COPD, was significantly higher than

Australia as a whole (260 ASR) and somewhat higher the two Brisbane and the Gold Coast

PHNs (271-280 ASR). It was similar Central Queensland Wide Bay Sunshine Coast PHN

(327 ASR) and lower than Darling Downs West Moreton and Western Queensland PHNs

(354-580 ASR)25. In 2015/16, 2244 residents were admitted for an average of 4.3 days for

management of COPD (Table 4).

Overall there were 9,633 potentially preventable bed days linked to this disease. There also

appeared to be a worsening trend over the three years of data.

Table 4: Potentially preventable hospitalisations for COPD, NQPHN

COPD ASR PPH / 100000 Cases Bed days

2013-14 294 1948 9299

2014-15 316 2159 9347

2015-16 319 2244 9633

24 AIHW, AIHW.gov.au/copd, Canberra


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Chronic heart failure (CHF)

Chronic heart failure affects about half a million Australians and costs the economy $1

billion annually26. General practitioners, together with heart failure nurses and allied health

professionals, play a key role in managing this condition.

In 2015/16 in the NQPHN catchment the age standardised rate of 224 (per 100,000

persons) of potentially preventable hospitalisations for CHF fell in the mid-range of rates for

the other Queensland PHNs (195-239 ASR) excluding Western Queensland PHN (313

ASR)27. In Northern Queensland in 2015/16, 1,523 residents were admitted for an average

of 6.2 days for management of CHF. Overall there were 9,637 potentially preventable bed

days linked to this disease (Table 5).

Table 5: Potentially preventable hospitalisations for CHF, NQPHN

CHF ASR PPH / 100000 Cases Bed days

2013-14 208 1315 7756

2014-15 213 1399 8361

2015-16 224 1523 9367

There are two types of CHF: left ventricular systolic dysfunction (LVSD) (the breathless

patient with a large heart that contracts poorly) and heart failure with preserved ejection

fraction (HFPEF) (the breathless patient with normal left ventricular eject ion fraction). More

people worldwide are admitted to hospital with HFPEF than LVSD but mortality is similar for

both types of CHF. Most LVSD is caused by myocardial infarction whereas HFPEF is due to

diabetes and hypertension.

26 MJA 2013; 199:334.


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The role of the allied health workforce in improving chronic disease

outcomes

The ongoing care needs of people with diabetes, COPD and CCF are mainly addressed by

primary health services instead of acute hospital services. Allied health care is essential for

achieving high quality outcomes for patients with these chronic diseases.

Reducing diabetes complications

Maintaining blood glucose levels, blood pressure, and cholesterol at or close to normal can

help delay or prevent diabetes complications. Therefore, people with diabetes need regular

monitoring and comprehensive, multidisciplinary management.

Cardiovascular disease is the most common cause of death in people with diabetes. High

blood pressure, high cholesterol, high blood glucose and other risk factors contribute to

increasing the risk of cardiovascular complications.

Kidney disease is much more common in people with diabetes than in those without

diabetes. Maintaining near normal levels of blood glucose and blood pressure can greatly

reduce the risk of kidney disease.

Diabetes can cause damage to the nerves throughout the body when blood glucose and

blood pressure are too high. This can lead to problems with digestion, erectile dysfunction,

and many other functions. Among the most commonly affected areas are the extremities, i n

particular the feet. Nerve damage in these areas is called peripheral neuropathy, and can

lead to pain, tingling, and loss of feeling. Loss of feeling is particularly important because it

can allow injuries to go unnoticed, leading to serious infections and possible amputations.

People with diabetes carry a risk of amputation that may be more than 25 times greater than

that of people without diabetes. However, with comprehensive management, a large

proportion of amputations related to diabetes can be prevented. Even when amputation

takes place, the remaining leg and the person’s life can be saved by good follow -up care

from a multidisciplinary foot team. People with diabetes should regularly examine their own

feet or have someone else check them instead.

Most people with diabetes will develop some form of eye disease (retinopathy) causing

reduced vision or blindness. Consistently high levels of blood glucose, together with high

blood pressure and high cholesterol, are the main causes of retinopathy. It can be managed

through regular eye checks and keeping glucose and lipid levels at or close to normal.

Women with any type of diabetes during pregnancy risk a number of complications if they do

not carefully monitor and manage their condition. To prevent possible organ damage to the

foetus, women with type 1 diabetes or type 2 diabetes should achieve target glucose levels

before conception. All women with diabetes during pregnancy, type 1, type 2 or gestational

should strive for target blood glucose levels throughout to minimize complications. High

blood glucose during pregnancy can lead to the foetus putting on excess weight. This can

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lead to problems in delivery, trauma to the child and mother, and a sudden drop in blood

glucose for the child after birth. Children who are exposed for a long time to high blood

glucose in the womb are at higher risk of developing diabetes in the future.

Management of diabetes complications is therefore multidisciplinary and needs to be

comprehensive to be effective. Lifestyle management is crucial, as is weight loss if

overweight. Bariatric surgery can be considered for people with BMI of 30 or higher, with

suboptimal blood glucose levels and increased cardiovascular risk. Aggressive management

of blood pressure and lipids reduces cardiovascular risk. Medication management is often

complex and assessing compliance regularly is important.

Members of the multidisciplinary team, in addition to the general practice team, are:

dietitians / nutritionists;

diabetes educators;

podiatrists / foot care attendants

optometrists; and

pharmacists.

Diet, weight control and physical activity should be regularly discussed. Exercise

physiologists may therefore also have a role in the multidisciplinary team.

Patients who have had bariatric surgery require additional multidisciplinary management.

Medical, nursing and allied health team members require expertise in nutritional and medical

management of patients with bariatric care needs.

Improving COPD outcomes

The most recent COPD guidelines in Australia were released in 2015, together with a

concise guide for primary care. There are five components to the guidelines28:

C – case finding and confirm diagnosis

O – optimise function

P – prevent deterioration

D – develop a plan of care

X – manage exacerbations

Spirometry is recommended in all patients with suspected or known COPD. Other

investigations may be ordered to confirm or exclude other conditions that may present

similarly to COPD (e.g. chest x-ray to exclude other lung disease, blood count for anaemia

or polycythaemia and exercise stress tests, electrocardiograph and / or echocardiogram to

diagnose cardiovascular disease).

Once diagnosed, treatment involves medication management, smoking cessation for all and

pulmonary rehabilitation for all people with COPD. The majority of people with COPD are

28 Lung Foundation of Australia, COPD-X Concise Guidelines for Primary Care, Brisbane 2017

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managed in primary care. Specialist referral is only needed for complex patients, young

patients (age < 40 years at onset, or where there is diagnostic uncertainty). Surgery is rarely

indicated for people with COPD. Home oxygen is used in patients with severe or end-stage

COPD.

Patients with COPD need a plan of care with management goals, including self -

management, and the involvement of multidisciplinary team members. In addition to the GP,

core team members are:

Physiotherapists / exercise physiologists (for managing infective exacerbations /

pulmonary rehabilitation);

Pharmacists;

Psychologists;

Practice nurses / nurse practitioners; and

Carers / support groups.

Treatment goals are short term (reduce symptoms and improve quality of life), medium term

(reduce exacerbations and hospital admissions) and long term (reduce mortality).

Short term improvement is achieved through medication management. Medium term goals

are the highest priority for the multidisciplinary team as exacerbations reduce quality of life,

may be fatal and contribute to faster decline in lung function. Further, nearly 60% of the

global cost of COPD is related to the management of exacerbations, most of this in hospital

costs29.

To reduce the number of exacerbations requiring hospital admission, management

comprises adjusting bronchodilators to symptoms, starting oral steroids if breathlessness

interferes with activities of daily living and starting antibiotics if increased volume and

change in the colour of sputum.

The role of self-management is controversial. Earlier studies suggested self-management is

safe and effective30. However, more recent evidence has found an increased risk of death in

the self-management group. A recent RCT was stopped early because of increased deaths

in the self-management group31.

Similarly, the results of telemonitoring in COPD are inconclusive. A Cochrane review in 2012

suggested it reduced hospital admissions32. Subsequent evidence showed no difference in

exacerbations, hospitalisations, quality of life or mortality with telemonitoring 33.

29 Chest 2009; 136: e30. 30 Cochrane Library 2009; CD 002990. 31 Annals of Internal Medicine 2012; 156: 673. 32 British Journal of General Practice 2012; 62: 576. 33 BMJ 2013; 347: f6070.

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Long-term, COPD is a progressive illness and patients palliative care needs should be

identified and addressed when timing is appropriate. Prognosis and treatment response are

assessed using the BODE index (BMI, airflow Obstruction, Dyspnoea, Exercise capacity)

and requires a six-minute times walking test to be performed. Multidisciplinary palliative care

team involvement during the palliative phases of the illness improves symptom control34.

Reducing CHF morbidity and mortality

The Heart Foundation guidelines on the prevention, diagnosis and management of heart

failure recommend GPs obtain a specialist opinion for all people with CHF as specialist

involvement improves outcomes and reduces hospitalisations. This is challenging for people

living in rural settings.

Management of heart failure is multidisciplinary and involves education, lifestyle changes

and rehabilitation. Patients with CHF need to stop smoking, have annual immunisations and

participate in regular physical activity which is ideally in the form of a structured

rehabilitation program. Key members of the primary care team are therefore the GP, heart

failure nurse and exercise physiologist or physiotherapist.

Exercise is safe in heart failure. Randomised controlled trial evidence in patients with severe

heart failure (NYHA 3 and 4) demonstrates no safety problems with exercise rehabilitation

supervised by physiotherapy / exercise physiology versus exercise that is not directly

supervised by these allied health professionals35. The role of the allied health professional is

to recommend an appropriate rehabilitation plan, rather than to supervise all aspects of the

patient’s rehabilitation.

Self-management is important for people with CHF. Patient should weigh themselves every

morning and report any weight gain of more than 2kg over two days to their GP or heart

failure nurse.

Workforce challenges in the delivery of allied health care

Undersupply and maldistribution of allied health professionals (AHPs) in rural and remote

areas is a persistent global problem36. As a geographically large and relatively sparsely

populated country, Australia is no exception and gaps in access to health services have

been evident for many decades37.

34 Therapeutic Guidelines. Palliative Care, 2010. 35 JAMA 2009; 301: 1439. 36 Smith K, Humphreys J, Wilson M: Addressing the health disadvantage of rural populations: How does epidemiological evidence inform rural health policies and research? Australian Journal of Rural Health 2008, 16(2):56–66. 37 Australian Institute of Health and Welfare (AIHW): Rural, regional and remote health: indicators of health status and determinants of health. Canberra: AIHW; 2008. Contract No.: no. 9. Cat. no. PHE 97.

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Australia-wide there is a chronic shortage of AHPs working in rural and remote locations38.

Australians in metropolitan areas receive more than double the level of service provision

from physiotherapists, podiatrists, occupational therapists and social workers as those living

outside of urban areas39. This discrepancy becomes more pronounced as the degree of

remoteness increases, with the ratio of allied health professionals to population falling from

2.2 per 10,000 in capital cities to between 1.4 and 1.8 in regional areas, 1.2 in remote areas

and 0.6 in very remote areas40.

Many allied health services result from referrals from GPs and specialists. The Australian

Institute of Health and Welfare (AIHW) reports the following for remote areas in Australia41:

58 generalist medical practitioners per 100,000 population (compared with 196 per

100,000 in capital cities)

589 registered nurses per 100,000 population (compared with 978 per 100,000 in

major cities)

64 allied health workers per 100,000 population (compared with 354 per 100,000 in

major cities).

Increasing access to allied health care is an important component of improving regional,

rural and remote health outcomes. Currently the AHP disciplines registered with the

Australian Health Practitioner Regulation Agency (AHPRA) include: Aboriginal and Torres

Strait Islander health practitioners, Chinese medicine practitioners, chiropractors, dental and

oral health providers, medical radiation practitioners, optometrists, osteopaths, pharmacists,

physiotherapists, podiatrists and psychologists42. Other AHP disciplines are yet to attain

national registration and accreditation. These include audiologists, social workers,

orthoptists, speech therapists, orthotists and prosthetists, dietitians and radiographers.

Nationally AHPs account for approximately 25 percent of the health workforce43.

Maldistribution of AHPs varies according to the specific discipline of the AHP. Pharmacists

and occupational therapists have the least variation by geographical location (but there is

still one and a half times more of these AHPs in cities compared with rural and remote

locations)44 45. Medical radiation practitioners and psychologists have the greatest disparity

38 Australian Institute of Health and Welfare. (2012). Allied health workforce 2012. Nat ional health workforce series no. 5. Cat. no. HWL 51. Canberra: AIHW. Canberra: AIHW. 39 Ibid 40 Ibid 41 Swerissen, H., Duckett, S., and Wright, J., 2016, Chronic failure in primary medical care, Grattan Institute 42 http://www.ahpra.gov.au/National-Boards.aspx 43 AIHW. (2014). Australia’s allied health workforce is growing. Retrieved from http://www.aihw.gov.au/media-release-detail/?id=60129549972 44 AIHW. (2016c). Table 1: Registered occupational therapists: selected characteristics by workforce status and principal role, Australia, 2012 to 2014. 45 AIHW. (2016e). Table 1: Registered pharmacists: selected characteristics by workforce status and principal role, Australia, 2011 to 2014.

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in supply variance between metropolitan and remote/very remote areas, with a metropolitan

FTE rate almost three times that of remote/very remote areas46 47.

Other health workforce gaps

Health and community services in rural and remote areas are different to those in the city.

Health facilities are generally smaller and provide a broad range of services, including

mental health services, oral health, community and aged care, and human services.

Services themselves generally have less infrastructure and, where more complex services

are delivered, provide these in lower volumes than city providers deliver.

Rural and remote health and community services generally depend more on generalist

service providers, including GPs and registered nurses. There is limited availability of allied

health professionals in most rural and remote areas. Some specialist services may be

available locally whereas others are provided by ‘visiting’ health professionals.

People in rural areas need to travel further to access health and community services and

receive a smaller share of overall health spending48. They face larger logistical challenges in

accessing health services and are more likely to undergo overnight or prolonged hospital

stay. This is related to fewer available GPs, specialist nurses and health professionals and

more limited access to specialist services.

Health and community service planning and delivery have traditionally been developed with

a focus on urban settings. As a result, service models and models of care are often in place

that are better designed to meet the needs of larger cities and towns than those of rural,

regional and remote communities.

The number of GPs for a given population tends to increase as remoteness increases due to

the relatively sparse and small populations in remote Australia (Figure 1).

46 AIHW. (2016a). Table1: Registered medical radiation practitioners: selected characteristics by workforce status and principal role, Australia, 2012 to 2014. 47 2016h 48 National Rural Health Alliance 2010. Measuring the Metropolitan-rural Inequity.

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Figure 1: GPs per 100,000 population by state and remoteness area49

In Queensland, the number of GPs per 100,000 population increases with increasing

remoteness. However, these data do not reflect the increased distance people will have to

travel to access their GP, the increased costs often associated with GP appointments in

rural areas, and the decreased choice patients have with respect to their GP50. In 2013–14,

nearly one in three people living in outer regional, remote or very remote areas nationally

waited longer than they felt acceptable to get an appointment with a GP compared with just

over one in five in major cities51.

Hospital services are an important part of contemporary health care. Equitable access to

hospital services is a significant political and social issue for rural communities. However,

rural and remote hospital services are expensive to provide. This relates to the high fixed

costs of operation, their inability to achieve the economies of scale of larger hospitals due to

the small size of the catchment population, and difficulties attracting and retaining a

sustainable and suitably skilled clinical workforce. Medical services in these hospitals are

often provided by specialist general practitioners, rather than other medical and surgical

specialties.

For most rural and remote communities, access to hospitals is also affected by:

the need to travel to access some hospital services;

transport, accommodation, financial, family and employment related impacts of

accessing services away from home; and

49 COAG Reform Council 2012. Healthcare 2010-11: Comparing performance across Australia. Canberra. 50 Australian Bureau of Statistics, 4839.0. Patient Experiences in Australia: Summary of Findings, 2013–14. 51 Australian Bureau of Statistics, 4839.0. Patient Experiences in Australia: Summary of Findings, 2013–14.

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a lack of choice and limited availability of health care services, particularly private

hospital services.

Allied health service gaps in northern Queensland

Service maps that describe the geographical location of allied health professionals are often

misleading. The presence of an allied health professional in a geographical area does not

necessarily guarantee that the professional is targeting the neediest patients, the

community’s highest priority health needs or that the service being delivered is accessible,

effective and of the best quality possible, given available resources.

Notwithstanding these limitations, findings from service mapping undertaken for this review

highlight the maldistribution of allied health services between regional and rural areas in

northern Queensland (Appendix 2).

Our analysis, drawing on multiple sources, attempted to identify the frequency of services

available in each LGA for each of the seven allied health professions. A score of three or

less, indicated the availability of the service less than monthly. Table 6 shows the 18 local

government areas (LGAs) (out of a total of 30 LGAs in the NQPHN catchment) that were

scored 1-3 and therefore have the highest relative service deficit. The full analysis is

presented at Appendix 2.

Table 6: Summary findings, allied health service mapping, northern Queensland

LGA Diab Educ

Dietetics Nutrition

Podiatry Physio Ex Phys OT Social Work

Aurukun X X

Charters Towers X

Cook X

Croydon X X X X X

Etheridge X X X X X X X

Hinchinbrook X

Hope Vale X X X

Kowanyama X X

Lockhart River X X

Mapoon X X X

Napranum X X

Nth Pen. Area X X

Pormpuraaw X X X X

Tablelands X

Richmond X X

TS Island X X X X X X

Wujal Wujal X X X X X

Yarrabah X

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Recent initiatives to build the rural and remote allied health workforce

Both the Queensland and Australian governments have implemented a range of initiatives to

support recruitment and retention of allied health professionals in rural areas.

Australian Government

The Australian Government’s rural locum assistance program (Rural LAP) consolidates

three separate schemes: the Nursing and Allied Health Rural Locum Scheme (NAHRLS),

the Rural Obstetric and Anaesthetic Locum Scheme (ROALS) and the Rural Locum

Education Assistance Program (Rural LEAP). Rural LAP enables eligible health

professionals to access continuing professional development or to take leave for recreation

purposes. It supports health workforce in rural locations, as well as enhancing the rural and

remote health workforce capacity. The Rural LAP also benefits urban health professionals

wishing to experience rural or remote practice by undertaking a locum placement or for GPs

to undertake additional training so that they undertake locum work in non-urban Australia52.

The Nursing and Allied Health Scholarship and Support Scheme was an Australian

Government initiative to support nursing and allied health scholarships. The allied health

element of NAHSSS was administered on behalf of the department by Services for

Australian Rural and Remote Allied Health (SARRAH). SARRAH now works with health and

education sector partners from across Australia on the allied health rural generalist

pathway. The pathway is a strategy to build the capacity, value and sustainability of allied

health services and multi-disciplinary teams in rural and remote areas. The components of

an allied health rural generalist pathway are53:

service models that address the challenges of providing the broad range of

healthcare needs of rural and remote communities;

Workforce and employment structures that support the development of rural

generalist practice capabilities; and

an education program tailored to the needs of rural generalist practitioners.

The Allied Health Professions Office of Queensland (AHPOQ) in Queensland Health, in

consultation with health sector partners in other states and territories formed an agreement

with James Cook University (JCU) in collaboration with Queensland University of

Technology (QUT) to progress development of the Rural Generalist Program. Level 1 of the

program was available for enrolment in 2017 and Level 2 in 2018. The Rural Generalist

Program is a two-level, university delivered program, encompassing rural generalist practice

development for seven professions: medical imaging, nutrition and dietetics, occupational

therapy, pharmacy, physiotherapy, podiatry and speech pathology54.

52 http://www.health.gov.au/internet/main/publishing.nsf/Content/rural -locum-assistance-program 53 https://www.sarrah.org.au/ahrgp 54 https://www.sarrah.org.au/sites/default/files/docs/info_1._overview_20170811_revised.pdf

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Queensland Health

Queensland Health has administered a small number of rural scholarship programs for allied

health professionals for some years. The main program was the Queensland Rural and

Remote Scholarship Scheme, which bonded undergraduate students to rural employment

within Queensland Hospital and Health Services (HHSs). The allied health component of

this scheme commenced in 199655.

The overall program faced several challenges including its management being very labour

intensive and expensive, and difficulties sourcing an adequate number of vacant rural or

remote positions appropriate for a new graduate in which the scholarship holder could

complete the return of service period. Over the same period there were changes in the

profile of the workforce and requirements for training. From the late 1990s to the early

2000s, there was a shift from a shortage of students to a shortage of employment

opportunities for new graduates. Queensland Health subsequently reviewed their

organisational approach to allied health workforce sustainability, and in response,

repurposed funding from the scholarship scheme and several smaller rural and remote

initiatives in order to introduce the Allied Health Rural Generalist Training Program,

AHRGTP56.

The aims of the AHRGTP were to57:

Increase employment opportunities for early career AHPs in rural and/or remote

health services.

Establish and evaluate a model for early career employment in rural and remote

areas which includes addressing requirements for training, development, and on-

going support.

Enhance opportunities for exposure to rural and/or remote service, incentivise rural

and remote practice for early career professionals, and support sustainability of the

rural and remote allied health workforce.

Trial rural and remote allied health generalist model of care (MoC) in each AHRGTP

site which may include implementation or expansion of telehealth services or other

forms of service re-design, and / or workforce re-design including delegation and skill

sharing / trans-disciplinary practice.

Expressions of interest (EOI) were held to host a position through the AHRGTP in a rural or

remote location. A merit-based selection process was used in which each service was

required to demonstrate unmet needs and unmet service demand in their community. The

EOI process resulted in selection of 11 positions across nine health services in the latter

part of 2013. Four positions were awarded in the NQPHN catchment58:

55 https://www.health.qld.gov.au/__data/assets/pdf_file/0020/145910/ahrgtpreportatta.pdf 56 Ibid 57 Ibid 58 https://www.health.qld.gov.au/__data/assets/pdf_file/0020/145910/ahrgtpreportatta.pdf

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a Cairns and Hinterland Health Service recruit with a physiotherapy focus, based in

Innisfail, predominantly hospital-based;

a Cairns and Hinterland Health Service recruit with a dietetics focus, based in

Atherton;

a Mackay Health Service radiography position; and

a Cape York Health Service radiography position.

Thus, the impact of this program on overall allied health workforce capacity development in

North Queensland was limited, particularly in relation to community-based chronic disease

management.

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Stakeholder views on the current delivery of allied health care

Stakeholders characterised the northern Queensland chronic care system as:

characterised by competition for scarce resources;

fragmented and poorly coordinated;

complex for providers and consumers to navigate;

shaped by workforce shortages and skills gaps;

needing to improve access to services and cultural awareness; and

having variable levels of role delineation and governance and requiring better

monitoring and evaluation of existing chronic care services.

Arrangements which preference a competitive rather than cooperative approach to service

delivery, often through a reliance on a visiting workforce, whilst often necessary in current

circumstances, is high cost and leads to fragmentation not integration of care.

Competitive not collaborative service arrangements

Stakeholders consistently identified competition for funding as a defining characteristic of

the chronic care service system in Northern Queensland. Stakeholders attributed this to

multiple service provider organisations competing for limited funding, short funding cycles,

the shift to a market-based system where providers are required to compete for funding, and

low levels of trust between organisations in part due to unprecedented reform and

competition for scarce resources. As one stakeholder said,

It’s a really competitive landscape and such a hard environment with all the

different buckets of funding.

We end up doing micro service planning because it is such a dysfunctional

environment… We need shared planning and funding systems.

There were also stakeholders who identified the need for executives to lead by example in

embracing collaboration and role modelling a non-competitive approach to providing chronic

care:

Good will and genuine collaboration has to happen at the CEO level.

Of those organisations consulted, several were expanding or consolidating existing services

and revenue streams. Almost all expressed concern about the prospect of funding being

reduced or diminished as it would have a direct impact on staffing and on services available

in the community. Stakeholders attributed the culture of competition to reduced funding and

major reforms across the sector, political decisions which had an adverse impact on the

chronic care system. As one stakeholder said:

There have been major disinvestments in social and preventative health,

nutrition, environmental health, transport, food supply…it’s no wonder more

people end up in hospital.

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There seemed to be broad recognition that the culture of competition and uncertainty was a

problem with many stakeholders expressing a readiness to change and to collaborate.

Representative of these sentiments is that:

The culture of ‘survival’ stifles innovation – we need to change that.

Other stakeholders also took issue with the reactive approach to designing and delivering

health care services, identifying a correlation between political decisions about funding and

a culture of poor planning and ‘knee jerk’ service provision. Representative here:

Figure out what connected up teams you need to have first and then look at

funding opportunities. Don’t just spend money because you have it.

Notwithstanding concerns about competition, a key community-based stakeholder

highlighted the opportunities that it can generate when coupled with the right motivations

and ensuring the patient and the community are always the strategic and organisational

focal point:

We can choose to be competitive or collaborative – we can choose not to

focus on the fear of viability and focus instead on the best outcomes for our

community and the individuals we are here to care for.

It is important for NQPHN to be aware of and responsive to this culture of uncertainty and

competition and to look at ways to commission chronic care that reduce, rather than fuel it. It

is also important to distinguish constructive competition that drives market and service

improvement and ultimately aims to improve care for consumers, from the more destructive

competition outlined above. As the discussion in preceding sections highlights,

commissioning is designed to create constructive competition and the commissioners has a

role in facilitating and leading that.

Overall, stakeholders thought that NQPHN had a key role to play in bridging the gap

between the acute and the primary and community care sectors, and getting partners and

stakeholders together to co-plan how best to commission chronic care.

Another finding was that in its approach to commissioning, NQPHN should be looking to

foster collaboration and innovation through its tender processes; grant tenders based on

their ability to demonstrate local knowledge, relationships, and capacity building; and put

strategies in place to accommodate flexible and holistic services best positioned to address

chronic care needs at the community level.

Stakeholders did however caution that whilst partnerships and collaboration are a strength

of the chronic care system, some also made the point that there can be a lack of clarity

around the nature and purpose of partnerships where this can erode willingness to

collaborate. Below is select feedback from stakeholders:

It is clear we need to work in a partnership, but we are not engaged in any

significant way.

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We need to know who the partners are, why they are in partnership, what

kind of partnership it is, and what we are here to do. Then we need to know

who is doing what and hold everyone to account… this includes turning up

to meetings.

Fragmented and poorly coordinated chronic care services

Stakeholders felt that the competitive market-place also contributed significantly to another

detrimental aspect of current services, that of fragmentation and poor integration of

services, a situation often made more problematic by a reliance on fly in/fly out and drive-

in/drive-out service. Many stakeholders shared the view that:

The issue is not a lack of services, it is a lack of coordination of services.

Most stakeholders had examples of rural and remote communities where multiple service

provider organisations were providing chronic care under a range of different funding

sources, with generally poor coordination of care for local patients due to limited, if any,

communication between different providers. Anecdotally, there were multiple examples in

each region of patients seeing two or three different providers from different organisations

within days of each other without any of those providers knowing they had seen the same

patient for the same condition.

In the context of consultations, our consultants were informed of various service provider

organisations, and consulted with representatives from most of these. By way of illustration

we have identified at least 14 major services, partly or fully funded, directly or through

contract, by one or other level of government.

Suggestions as to how NQPHN may improve the situation include prioritising tenders that

involve clearly defined roles for service hosts, a nominal fee to support service coordination,

and brief (verbal or written) reports provided by representatives at the service host and

service provider organisation. The idea here was that doing so could facilitate discussion

between stakeholders and be a mechanism for early identification of issues associated with

the service. Another approach was to ensure those who tender for chronic care funding

demonstrate effective local relationships, referral pathways, support for the local workforce

to manage patient care between visits, and communication strategies to ensure patients

who most need the services can access them.

Some stakeholders also thought there would be merit in NQPHN working more closely with

organisations that fund outreach services to the same communities to look at opportunities

to leverage off what is already funded and provided. For example, in cases where CheckUP

or an HHS is already funding a high-need service (say, a diabetes team), and the local

workforce could benefit from upskilling support or additional visits by that provider (whether

face-to-face or via telehealth) NQPHN could look at opportunities to co-fund with those

organisations to maximise efficiencies and minimise duplication.

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Stakeholders also saw a role for NQPHN as commissioning organisation to performance

manage any commissioned service providers who were not collaborating effectively and / or

whose services were not well integrated with the local service system.

Stakeholders saw opportunities for NQPHN to be more responsive to the challenges

associated with outreach when commissioning chronic care into the future. One stakeholder

put it as follows:

When PHNs do contracts… services need to be linked so people

understand what the service is, what their role is [so that] local providers

can refer.

A complex system to navigate

Overall, stakeholders regarded the complex array of service providers as a barr ier to

integrated chronic care. They also agreed that fly-in-fly-out and drive-in-drive out (outreach)

service provision, while necessary, is inherently costly, unsustainable, and complex for

patients and local service providers to understand and navigate. As one stakeholder said:

It is so confusing for patients…they don’t know who funds what, they just

want to arrive and get care.

For some we [local clinical staff] know what’s going on and whose coming

and what works well but generally we don’t.

Another stakeholder made the point that with so many different fly-in/fly-out drive-in/drive-

out providers doing services in rural and remote areas, it can create confusion and mean

neither patients nor local providers know what service is available when:

Disconnected, disjointed models of service compromise patient safety and

continuity of care… then it is the patients that get labelled as ‘non-

compliant’.

Problems with workforce recruitment, retention and capability-building

Overall, stakeholders identified attracting and retaining suitably qualified clinicians as a

major issue particularly in more rural and remote areas as the demand for services in these

areas continues to grow.

The main workforce capacity issues relate to a limited allied health workforce across the

region, high turnover of staff (particularly GPs where this adversely affects referrals to allied

health), and patients developing chronic diseases earlier and living longer with more

comorbidities and complex care needs. Other workforce issues related to system challenges

such as individual clinicians / professions not working to their full scope of practice and a

context shaped by reform and politics which can present barriers to innovative workforce

models. One example discussed in consultations was putting the systems in place for

physician assistants to readily support rural and remote general practice: while there are

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currently physician assistants in Queensland who are trained and highly skilled, the current

MBS billing system means that there are financial and administrative disincentives for rural

and remote general practices to appoint them as doing.

Service managers said it can be really challenging to recruit and retain allied health

professionals to provide outreach due to the travel, long hours, and because - in the

absence of effective relationships between the service provider, the local chronic care

workforce, and the service host, so providing safe, high-quality care is difficult. Stakeholders

said:

No one thinks about the back-end considerations such as quality, having

safe systems in place, transporting patients, patient records, and so forth.

Retaining staff who do outreach requires serious relationship management.

Despite overall concerns about workforce capacity in the region, most stakeholders were

optimistic and saw the challenge for chronic care as working smarter with the available

resources, rather than assuming there would necessarily be an increase in sustainable

workforce in the region. As one stakeholder put it:

We need to work smarter with the workforce we’ve got, not assume more

services and service providers is always better.

In terms of workforce capability building, the main themes related to untapped opportunities

to leverage the local workforce in rural and remote areas and to put strategies in place to

support the existing workforce to use their full scope of practice. Two stakeholders made the

following comments:

There’s a huge gap: Indigenous Health Workers and remote area nurses

can lose their skills – you need to get people working to their full scope of

practice.

It is really hard to recruit up here [Northern Queensland], to build a

workforce and grow it59

Stakeholders highlighted the need to invest in supporting the development and capacity of

the generalist workforce:

We need generalist allied health professionals…in rural and remote areas

you need to be able to treat and manage the whole spectrum of ages and

conditions.

In keeping with the comments above, stakeholders also highlighted the need to put

strategies and training in place to ensure minimum competencies in chronic care

59 As an aside, a similar point was made with respect to recruiting to health administration and the NQPHN

workforce.

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management were maintained. Some suggested this could be a joint initiative between

NQPHN, the HHSs, and other training and service provider organisations.

Stakeholders identified various innovative workforce models in the context of consultation.

These include, but are not limited to:

continuing to invest in allied health assistants across the region60 and looking at

opportunities to link allied health assistants to services provided outside Queensland

Health;

looking at opportunities to support innovation in the skilled generalist workforce such

as Physician Assistants and Nurse Practitioners. As a case in point, James Cook

University runs course for both Physician Assistants and Nurse Practitioners61.

investigating opportunities to mentor the regional support workforce;

investing in Indigenous Health Worker training and support to maximise the existing

workforce and provide opportunities for health workers to develop and maintain their

confidence and competence in chronic care management;

provide targeted Indigenous Health Worker, nursing and allied health training in rural

and remote locations that focuses on the unique challenges associated with

providing chronic care in a remote setting;

using telehealth to provide upskilling and remote supervision to the local workforce

on a routine basis and as part of commissioned services;

working with (private and public) allied health professionals, general practice staff,

hospital staff and consumers to raise awareness and provide information and

education on how different allied health professionals can contr ibute to a patient’s

chronic care62;

training in transfers of care to help clinicians understand what is available in local

communities;

investing in workforce development and training in cultural respect; and

improving uptake of Aboriginal and Torres Strait Islander Health Assessments (item

715), as well as other Chronic Disease Management item numbers across the board.

Barriers to accessing services, poor cultural awareness

Stakeholders identified room to improve consumer-directed / patient-centred care, with

many suggesting chronic care services can be designed and delivered based on the needs

of service providers/organisations rather than consumers and communities. This was

despite stakeholders acknowledging efforts to provide more consumer-directed care and

60 https://www.health.qld.gov.au/ahwac/html/ahassist

61 See, Duckett S and Breadon P 2013. Access all areas: New Solutions for GP shortages in rural Australia:

Grattan Institute; State of Queensland (Queensland Health) 2016. Physician Assistants in Queensland: Consultation Paper. http://www.acrrm.org.au/the-college-at-work/policy/policy/2014/08/13/position-statement-on-physician-assistants; https://www.health.qld.gov.au/ocnmo/nursing/nurse-practitioners

62 In keeping with this suggestion, North West Remote Health have information on different allied health

professions which is useful: http://www.nwrh.com.au/services/health-and-wellbeing-services/

https://www.health.qld.gov.au/ahwac/html/ahassist

http://www.acrrm.org.au/the-college-at-work/policy/policy/2014/08/13/position-statement-on-physician-assistants

http://www.acrrm.org.au/the-college-at-work/policy/policy/2014/08/13/position-statement-on-physician-assistants

https://www.health.qld.gov.au/ocnmo/nursing/nurse-practitioners

http://www.nwrh.com.au/services/health-and-wellbeing-services/

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individual service providers being very patient-centred and committed in their approach. One

stakeholder put it as follows:

We lose sight of the fact that coordination of care and joined up services is

about the patient.

Examples raised by stakeholders included service providers choosing not to provide

outreach to a more rural and remote area because it is more convenient for them to provide

a service from their private rooms. Conversely, a fund holder may continue to fund a service

because the service provider is willing to provide it rather than because it is all things

considered a high need service.

Associated issues identified were a western, biomedical approach which is not reflective of

the diverse population in the region and high proportion of Aboriginal and Islander peoples.

As two stakeholders put it:

We (service providers) expect them to come to us which is not culturally

appropriate

If a patient misses two appointments they are off the waiting list: cultural

respect? What about Sorry Business? The logistics of travel? There must

be a better way.

The comment above highlights a systems issue identified during consultation: there is a

need to improve the cultural appropriateness and safety of services across the board,

particularly in the ‘mainstream’ sector.

This finding is consistent with evidence and national policies which speak to the need to

ensure a holistic approach to health and wellbeing; recognise and respect the diversity of

Aboriginal and Torres Strait Islander peoples; a human rights approach; and the importance

of the social and cultural determinants of health63. According to the National Cultural

Respect Framework (2016) cultural respect is achieved by

a whole-of-organisation approach and commitment;

communication;

workforce development and training;

consumer participation and engagement;

stakeholder partnerships and collaboration; and

data, planning, research and evaluation.

63 Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing

Committee. Cultural Respect Framework 2016-2026 for Aboriginal and Torres Straits Islander Health: A National Approach to Building a Culturally Respectful Health System. See also

http://www.health.gov.au/internet/main/publishing.nsf/Content/AC51639D3C8CD4ECCA257E8B00007AC5/$File/DOH_ImplementationPlan_v3.pdf



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Stakeholders also identified pervasive limitations with access to transport and

accommodation despite both being high need, particularly for people travelling from remote

areas. More specifically, consumers identified a need for more cost efficient and effective

transport options as resources associated with travelling to larger centres for treatment can

be prohibitive, particularly for people living in more remote sub-regions. As one person put

it:

Our region could not cope with losing transport services – they are already

stretched.

Further, traveling whilst frail or unwell can be a huge barrier and at times, impossible.

Stakeholders provided examples of consumers travelling eight hours on a bus to receive

dialysis or finishing treatment in a hospital only to be discharged after hours and have no

access to transport or accommodation. Other issues raised by stakeholders included

patients re-presenting to the acute sector for an avoidable hospitalisation due to poor

transfers of care and a lack of communication between the tertiary and community sectors.

Even those with private health cover experienced prohibitive out-of-pocket expenses for

some aspects of their care. Stakeholders at a co-design workshop discussed an example of

someone with a longstanding and debilitating chronic condition who had gone years without

care which was available in their community because they did not have a concession, and

yet did not earn enough to self-fund.

Overall, the take home message from consultation was that

We need care closer to home, earlier, that is locally provided and

accessible.

While most stakeholders appreciated that not all services could be accessed in their home

town, there were some who thought the onus was on health system administrators and

service providers to develop more flexible and responsive approaches to care that meant

patients did not have to travel as much or as far.

In terms of suggestions about how NQPHN as commissioner could assist in addressing

some of these issues, stakeholders again identified opportunities to proactively increase

communication and bridge the gap between the tertiary, primary and community sectors;

look at opportunities to pursue projects focused on improving transfers of care; work with

Aboriginal and Torres Strait islander health organisations to increase uptake in cultural

awareness training; and more actively engage GPs and general practice staff in prioritising

health assessments and effective chronic disease care plans.

Several HHS based stakeholders saw a role for NQPHN in leveraging partnerships and

collaboration to improve the interface between the acute and the primary care sectors:

Our focus is acute, hospital-based services – how do you align that with

community and primary health care? NQPHN can help with that.

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Why wouldn’t we all be sitting at the same table? They [NQPHN] can help

make that happen.

Poor role delineation, governance, monitoring and oversight

In keeping with the challenges of service fragmentation one of the themes that emerged in

consultation was that there was room to improve role delineation and governance at both

the micro (service) and macro (inter-organisational) levels. Most stakeholders thought formal

partnerships and contractual levers were required to ensure people worked with, rather than

in opposition to or in isolation from others, with many making the point that merely talking in

terms of ‘partnership’ or being in principle involved in a partnership is not sufficient.

Stakeholders identified the need for formalising arrangements between organisations

involved in chronic care and clarifying lines of accountability and governance between them.

The key issue identified was that in the absence of clear role delineation and a shared

understanding of lines of accountability in transfers of care, patient can be and have been

adversely affected.

It is not clear which organisation owns the patient’s care plan

Where does the care plan sit? What’s the pathway?

We need really good clinical and professional governance with

relationships defined between the agencies and clarity around how the

services connect and interface…that starts with integrated planning,

Reported examples of how poor role delineation and governance adversely impacting

patients include patients travelling up to eight hours for renal dialysis only to be discharged

from hospital late at night, with no access to transport, a place to sleep for the night or

support. Another was patients being discharged from hospital post stroke only to represent

in the acute system or, worse, pass away due to avoidable complications and poor transfers

of care. Stakeholders saw a role for NQPHN in facilitat ing improved communication between

the acute, primary and community sectors to redress such issues.

Stakeholders also identified a lack of role delineation as a catalyst for poor coordination of

care and fragmentation. As one person put it:

Nobody has the discussion or specifies who is coordinating it [the outreach

service], what the outcomes of the service should be and how it links in

with the local service system…NQPHN contracts could do that.

There was recognition that ideally, chronic care services will be locally coordinated and

there will be contractual agreements and a shared vision between NQPHN, the HHSs and

other providers and partners about how best to manage transfers of care and who

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coordinates the patient’s care on the ground64. Many identified the need to improve

accurate, timely discharge and care plans accessible to all service providers involved in a

patient’s chronic care. Other issues identified in the context of discussion about role

delineation, quality and safety include:

clinically isolated health care providers operating in isolation of peer support and / or

clinical leadership;

allied health professionals, nurses and Indigenous Health Workers who may not treat

or manage sufficient patients to maintain their skills;

clinicians and support workers in regional and remote areas having to manage

patients without sufficient, or at times any, information about their previous care;

hospital-based clinicians underestimating the complexities of accessing follow up and

supportive care can in rural and remote locations; and

an accessible patient information management system covering the NQPHN region.

Stakeholders made the point that NQPHN funded services had not historically been closely

monitored or evaluated where this was seen as a potential risk to the quality of the services

and a missed opportunity to better understand and recognise services that were working

effectively.

Many stakeholders saw opportunities for NQPHN as a commissioning organisation to

embed more robust monitoring and evaluation into its procurement processes and take the

lead in modelling a willingness to make difficult and unpopular decisions based on evidence.

64 Even though the ReHP is a mechanism to improve coordination and transfers of care, stakeholders saw it as an innovation that would be most useful to and relevant for the TCHHS and CHHHS in the first instance.

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Improving models of allied health care

A range of allied health providers deliver services to rural and remote communities, either

based from within the community, or more often on a visiting basis. Pharmacy services are a

core, locally based service in most rural communities. Other services such as psychology,

podiatry, physiotherapy, social work, occupational therapy and speech pathology are also

provided to varying extent by a mix of state government, contracted and private providers.

Challenges experienced in recruitment and retention of allied health professionals into rural

areas, include access to workforce and cost of services. In order to address these

challenges, some communities have been actively looking at opportunities for innovation in

the workforce, investigating models such as allied health assistants in order to address

workforce priorities and local health service access. Opportunities exist to explore

alternative innovative workforce models to ensure sustainable access to care.

Access to high quality allied health care requires more than recruitment and retention of

allied health professionals to rural areas. It also requires communication and information

sharing between providers from different disciplines within the community, and strong

linkages between generalist health professionals working in local communities who are

delivering components of allied health care under the supervision and with the support of

specialist allied health professionals.

Allied health models of care - what the evidence says

Increasing access to allied health care is an important component of improving health

outcomes. However, the delivery of allied health care is not limited to allied health

professionals alone, particularly in rural areas.

Rural models of chronic care are likely to be different to those for urban areas because of

demographic and socio-economic differences, as well as fewer service providers. There are

also financial and organisation challenges associated with serving a small populat ion that is

widely dispersed (a situation common in Australia)65.

There are broadly nine different models of allied health care used in rural communities that

are relevant to this literature review66 67:

private allied health practices;

sessional employment of private practitioners by a third party;

centralised rural multi-disciplinary teams (MDTs);

local community MDT;

65 Bolda and Seavey 2001, p427. 66 SARRAH. Models of allied health care in rural and remote Australia. May 2016. 67 A model of care is ‘the distinct arrangement of services within which an allied health professional or professionals deliver care. A model of care provides a structure and processes of care through which the implementation and evaluation of services can occur’.

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disease-specific health units;

specialist outreach services;

telehealth as a model of care;

delegated models of care; and

hospital-based services.

In many rural and remote communities, nurses, allied health assistants, personal carers and

other professionals represent a viable alternative to a specialist allied health professional -

only model of direct service delivery68.

Private allied health solo practitioners

Private allied health solo practitioners are rarer in rural Australia compared with urban areas

because patient numbers decrease with increasing remoteness. Businesses struggle to be

both financially viable but also to have the minimum number of patients required for the

professional to maintain their specialist skillset. Nevertheless, for personal or professional

reasons, allied health professionals may choose to deliver care through private allied health

practices in rural areas.

Allied health professionals delivering care under this arrangement may struggle to

participate in professional development, engage in the delivery of team-based care and

have the quality of their professional practice monitored. These professionals therefore may

require support to integrate their delivery of care with the broader service system and

maintain their skills.

Sessional employment of private practitioners by a third party

Sessional employment of private practitioners by a third party enables larger businesses

(e.g. non-government organisations, government bodies or commercial entities) to employ

allied health professionals on a sessional basis to deliver care to a group of people in a

specific location or across various locations. The advantage of this type of arrangement

compared with private allied health solo practitioners is it provides overarching clinical

governance and support to the practitioner, greater opportunities for inter-professional

interaction, greater potential to attract a critical mass of patients that supports improved

service quality and the ability to collect data that evaluate the effectiveness and quality of

the delivered services.

These services may be delivered through a fly-in/fly-out or drive-in/drive out arrangement,

which decreases the provider’s engagement with the communities they serve. Further,

services may be delivered infrequently, with local community providers expected to manage

patients in the time periods between visits. In order to be successful, these models therefore

require visiting allied health professionals to be familiarised with the local health care team

68 Bolda EJ, Seavey JW. Rural long-term care integration developing service capacity. The Journal of Applied Gerontology, 2001; 20(4): 426-457, p426.

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and supported to maintain communication and information sharing with the team between

visits.

Centralised rural multi-disciplinary teams (MDTs)

Centralised rural multi-disciplinary teams (MDTs) usually work from a regional centre and

deliver services on an outreach basis. Unlike sessional employment of private practitioners,

these models focus on a whole team of allied health professionals working together across a

geographical area. Opportunities for collaboration and inter-professional interaction are

therefore greater and case conferencing clients with complex care needs more readily

supported. However, as with sessional employment of private practitioners, services are

usually delivered through a fly-in/fly-out or drive-in/drive out arrangement, which decreases

the team’s engagement with the community they serve and local providers are expected to

manage patients in the time periods between visits.

Strong linkages between MDTs and the local providers, ready lines of communication and

information sharing between visits, and an adequate range of allied health professionals on

the team strengthen these models. Models are well suited to being supported through

telehealth.

Local community MDTs

Local community MDTs are locally based teams within individual rural communities or in

major towns that are big enough to sustain an allied health workforce. The viability of these

teams is strengthened when the local team is a ‘hub’ for the delivery of services to even

smaller outlying areas, not just to patients within the town itself. Allied health care

components may not all be delivered by allied health professionals. For example, nurses

and aged care professionals, together with a voluntary workforce, may deliver some of the

more generalist components of the patient’s allied health care needs.

Inter-professional teamwork inherent in MDTs can be defined as “a dynamic process

involving two of more health care professionals with complementary backgrounds and skill,

sharing common health goals and exercising concerted, physical and mental effort in

assessing, planning or evaluating patient care”69. As the definition implies, it takes

commitment to a way of working focused on the holistic needs of the patient. It is also a

mechanism of maximizing the available workforce aimed at improving communication and

quality of care.

In order to be successful MDT models need clear lines of accountability and support to

allied health professionals, many of whom may reside outside the local district. For example,

an aged care worker may deliver foot care services to local community members but needs

access to a podiatrist to seek advice and support with more complex foot care needs. This

69 Harris M, Advocat J, Crabtree B, Levesque J, Miller W, Gunn J, Hogg W, Scott C, Chase S, Halma L, Russell G. 2016. Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries. Journal of Multidisciplinary Healthcare 9 pp 35-46 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743635/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743635/

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may be strengthened through the use of telephone or internet-based support (e.g. the ability

for the aged care worker to send photographs of feet to a podiatrist for their review).

Local community MDTs are well suited to being combined with fly-in/fly-out or drive-in/drive-

out allied health professional teams, delivering care in between specialist allied health

professional visits. Generalist workforce skills development, a clear scope of practice,

mechanisms for communication and information sharing with specialist allied health

providers and local clinical governance arrangements strengthen the quality of these

models.

Disease-specific health units

Disease-specific health units have a single disease focus. For example, diabetes care

teams deliver podiatry, optometry, dietetics and / or diabetes educator services to rural

communities, usually on a fly-in/fly-out or drive-in/drive-out basis. Similar to other fly-in/fly-

out or drive-in/drive-out models, these models are most effective when strong linkages with

local health care providers exist, with clear lines of communication and information sharing

between providers between face to face visits.

Specialist outreach services

Specialist outreach services are essential for providing access to services where even fewer

allied health specialists exists within a specific discipline. For example, child psychologists

are a sub-specialised workforce with few providers delivering services in rural areas at a

frequency that meets patient’s and local provider’s support needs.

The best way to deliver these services varies greatly between different geographical areas.

Given the need for timely access to child psychology services, technology (telephone,

telehealth) is an essential component to any specialist outreach service model where patient

care needs are time critical. Specialist services need to be well integrated with local health

care teams and with allied health professionals within their discipline. Where local allied

health professionals exist (e.g. psychology, social work) they may be called upon, through

necessity, to deliver some components of the patient’s allied health care needs.

Local health professionals and patients are best placed to provide advice about the best

way to deliver these services for their local context.

Telehealth

Telehealth as a model of care involves the delivery of health services via information and

communication technologies when the health consumer and allied health professional are

not in the same location. For the purposes of this literature review, telehealth as a model of

care involves the entire patient-professional interaction occurring through technologies in

lieu of any face to face component. This is separate to the use of telehealth to support the

delivery of face to face services, as described in the models above.

There are several telehealth models where a local health assistant or generalist health

provider may be present with the patient while they consult via technology with the allied

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health specialist. These models work best where there is reliable internet coverage and / o r

where technology sites (‘hubs’) with reliable internet connectivity, but also able to provide

the patient with privacy during their consultation.

Telehealth generally should not be used as a substitute for face to face health care if direct

interaction is available or if better health outcomes would be achieved by face to face

contact that is accessible to the patient. Local providers delivering care to the patient should

be involved in the service delivery, either through participation in consultations or through

high quality information sharing and communication between providers involved in the

patient’s care.

Delegated models of care

Delegated models of care are increasingly being trialled for application in rural and remote

areas. The focus of these models is the use of allied health assistants or generalist health

providers who take on a central face-to-face role for delivering allied health care. These

models of care are often integrated with other models described above, particularly those

with a fly-in/fly-out or drive-in/drive-out component.

In these models the role of the allied health professional can include training, supporting and

or advising the practitioner delivering the face-to-face care. The specialist allied health

professional should develop the patient’s plan of care and assess the patient once the care

has been delivered.

Generalist providers who are delivering allied health care under the supervision and support

of an allied health professional need a clearly defined scope of practice and high levels of

integration of their services with other local providers in the patient’s health care team.

Hospital-based services

Hospital-based services exist in many rural and regional locations across Australia. Allied

health professionals are often employed in some of the smaller hospitals and are a major

presence in regional hospitals. In general, the larger the hospital, the more likely the service

model is based on a medical model of delivery that is acute care focussed.

Hospital-based allied health professionals have an important role to play supporting their

colleagues working in community. Unfortunately, allied health services are often siloed,

preventing patients from receiving the most effective, efficient level of care they need in a

timely fashion. For example:

A patient with chronic diseases and foot care needs will ideally receive basic foot

care services (nail trimming, the application of heel balm) from a trained, supervised

generalist health provider who is not a podiatrist (level 1).

Generalist health providers will be alert to, and refer on to a community podiatrist,

patients in whom foot disease is more complex (level 2).

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Where the patient’s foot care needs are even more complex, they will have access to

a more specialised service, which may include endocrinology, vascular surgery and

hospital-based podiatry (level 3).

The same patient will move up and down these levels of care depending on their chronic

care needs at any given point in time.

This implies a need for hospital-based allied health professionals to be integrated into the

broader service system, to understand their role, and to have good lines of communication

and information sharing across different levels of care, including the ability to refer patients

appropriately to lower levels of care when clinically appropriate.

Co-design results - stepped models of allied health care

Stepped Care is a system of delivering clinical care, so that the most effective yet least

resource intensive care is delivered to patients first; only 'stepping up' to more

intensive/specialist services as clinically required.

Co-design participants in this review envisaged stepped models of allied health care that

provide continuity of allied health care as close to home as possible.

Stepped models of allied health care

The general premise underpinning stepped models of allied health care is optimisation of

workforce potential. It is very expensive to send a fly-in / fly-out allied health professional to

see patients for four hours out of a 10-hour day, especially if the patients are of low

complexity, and who could have been managed by appropriately trained and educated local

clinicians, such as nurses, aged care workers or Aboriginal health workers.

The co-designed stepped models of allied health care include the following features:

allied health care is delivered by local providers who work in partnership with visiting

allied health specialists;

local providers can include a broad range of professionals, including aged care

workers, Aboriginal health workers and personal carers;

visiting allied health specialists oversee the delivery of low complexity allied health

care by local providers only where it is safe and appropriate to do so;

local providers receive education and training to deliver straightforward, low

complexity elements of allied health care; and

local providers are supported by visiting allied health specialists and can discuss the

patient’s care needs and receive advice and support as required from the allied

health specialist.

The stepped model of care proposed by co-design participants for allied health care in rural

and remote Northern Queensland has three tiers (Figure 2).

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Figure 2: NQPHN stepped model of allied health care

In Tier 1, the registered allied health practitioner (AHP) has advanced education and

expertise in the relevant field which can be best utilized in assessing new patients and

instituting a care plan; treating complex review patients; providing a specialist consultative

service by telehealth; and supporting other team members.

The development of skilled staff who are resident in the community can reduce the need for,

and frequency of AHP visits.

Tier 2 requires the local skills development of, ideally an existing employee of a local health

service, who would be available during the usual hours of operation of the health service.

The presence of the staff member would be a coordination point for the service, provide an

effective conduit of information and reduce the need for AHP visits to the site. The staff

member, could according to professional status, affiliations and preferences be a community

services worker, registered nurse or a new classification of allied health assistant.

Tier 3 utilises the existing community services workforce, such as HACC workers, who

already visit people in their homes. The purpose would be to monitor patient progress, with

a view to providing structured updates to both Tier 2 and Tier 3 clinicians, so that decisions

about review and interventions can be made (Table 7).

Tier 1 - visiting allied health professional

Tier 2 - local clinican / health worker educated to

provide allied health care in partnership with visiting allied health professional

Tier 3 - out-reach community services worker to help monitor patient progress in the community under supervision of

local clinican and allied health professional

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Table 7: Modified tiered outreach model

Tier

Title Employment

status

Role

Tier 1

Registered

allied health

practitioner

(AHP)

Employed by

HHS,

independent

contractor

Direct clinical services for initial assessment and

ongoing complex care; consultative telehealth service

for allied health assistants / registered nurse.

Tier 2a Allied Health

Assistant

Employed by

local health

service or

HHS

In larger centres, works under remote supervision of

AHP. Provides primary interventions prescribed by

AHP, monitors progress, organizes scheduled or PRN

reviews by AHP.

Tier 2b

Registered

nurse, aged

care worker,

AHW

Employed by

local health

service or

HHS

In smaller centres, works in coordination with local

MO, and with support of allied health practitioner to

provide primary interventions prescribed by AHP,

monitors progress, organizes scheduled or as required

reviews by AHP.

Tier 3 Community

care worker

Employed by

council, local

health

service, HHS

Primary role is as a community care worker, provided

with additional education and tools to help monitor

patient progress.

Additional benefits of the stepped model of care include:

more timely access to care for local patients;

better identification of at-risk patients;

optimising use of resources, both in terms of AHP time and budget;

harnessing local support for service development;

increasing professional development and support for local workforce which may in

turn improve professional satisfaction; and

reducing the risk of burnout for AHPs when all clinics are face-to-face.

Co-design participants report that stepped models of allied health care can be supported

through:

developing clinical pathways that clearly describe the allied health care needs of

patients;

improving communication and information sharing between local clinicians and

visiting allied health professionals through the use of technology;

commissioning service solutions that are evidence-based and foster collaboration

between visiting and local providers; and

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ensuring formal arrangements are put in place to clarify accountabilities and

responsibilities between providers and provider organisat ions in order to minimise

clinical risk.

Telehealth to improve service continuity

Effective use of telehealth is a necessary prerequisite to implementing a stepped model of

care in rural and remote Northern Queensland. A dedicated change management strategy

will also likely be required to help clinicians, managers and patients to recognise the

benefits of telehealth and improve utilisation and reduce travel.

Extensive telehealth resources have already been deployed in northern Queensland through

HHSs, PHN precursor organisations, and non-government organisations. Individuals can

also access telehealth through their own personal devices. Research demonstrates high

levels of consumer satisfaction with telehealth and no significant differences in outcomes

between face-to-face and telehealth consults70. The opportunity therefore exists to leverage

this existing infrastructure to provide access to allied health services.

Telehealth works best, where there is71:

local support and recognition as to the value of the service;

an effective relationship between patients, local staff, and the clinician providing

telehealth services, which usually requires a previous face-to-face consultation and

rapport with that clinician;

infrastructure, connectivity and bandwidth at the service site or available on personal

devices;

a designated, local service coordinator to help set up the room, book clinics, and

support patients;

agreement in the local community that access to telehealth is more convenient and

preferable than to travel long distances for routine management;

transport available for higher need patients to brought to the telehealth hub.

Examples of effective telehealth discussed in the context of consultations included: Tele -

ICU72, Tele-Derm National73, the store-and-forward telehealth systems to assist in managing

70Representative her: Australian College of Rural and Remote Medicine 2016. Effectiveness of Telehealth Consultations: Clinical Conditions – What is the evidence for the effectiveness of telehealth; Bashshur, R. L., Shannon, G. W., et al. (2014). The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management. Telemedicine Journal and E-Health, 20(9), 769–800; Raven M, Bywood O. 2013. Allied health video consultation services. PCHRIS Policy Issues Review. Adelaide: Primary Health Care Research and Information Service, Allen, J. V., Davis, A. M., & Lassen, S. (2011). The use of Telemedicine in Pediatric Psychology: Research Review and Current Applications. Child and Adolescent Psychiatric Clinics of North America , 20(1), 55–66.

71 See https://www.sarrah.org.au/sites/default/files/docs/allied_health_and_telehealth_final_ -_19.10.12.pdf for a more detailed discussion of telehealth enablers with allied health service provision in rural Australia.

72 https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-16-Guidelines-on-the-Use-of-Telemedicine-in-Intensive-Care.pdf

73 http://www.acrrm.org.au/search/find-online-learning/details?id=1019

https://www.sarrah.org.au/sites/default/files/docs/allied_health_and_telehealth_final_-_19.10.12.pdf

https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-16-Guidelines-on-the-Use-of-Telemedicine-in-Intensive-Care.pdf


http://www.acrrm.org.au/search/find-online-learning/details?id=1019

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diabetic foot ulcers pilot in Queensland74, the Asthma and COPD Telehealth Service for

Country WA75, and hub and spoke diabetes retinopathy screening enhanced by telemedicine

technology76.

Given the findings above, NQPHN should look at ways to work with stakeholders to support

local service coordination for telehealth, as well as supporting the local workforce to ensure

patients who would benefit from telehealth can access it. There would also be merit in

NQPHN prioritising chronic care service models that include telehealth, as long as

consideration has been given by prospective service providers about how to implement a

model of care that includes telehealth in the region in question. This will require engaging

the local community and chronic care workforce.

Hub and spoke service systems

A mechanism to deliver the stepped model of care is provided through a ‘Hub and Spoke’

arrangement. Where a central hub ensures access to a specialised allied health workforce

necessary to support services in distant towns, the spokes. The services are typically

frequent, scheduled consultative telehealth services and less frequent visiting services. The

hub undertakes primary responsibility to ensure ongoing and continuous access to the

necessary skilled workforce. A public or private sector organisation can be contracted to be

the hub.

Entrenching principal responsibility for guaranteeing access to the qualified workforce with a

central hub also more easily enables the implementation of strong role delineation and

clinical governance responsibilities in contracts.

Stakeholders supported the model on the proviso that the local workforce is engaged in

developing and implementing the service model.

Various examples of hub and spoke models were discussed during consultation. These

included the Footcare Networks in the UK77; outreach rehabilitation programs for patients in

rural and remote NSW78; Wimmera Cardiac Rehabilitation Hub and Spoke Telehealth

Model79, Victorian Paediatric Rehabilitation Service80; Central Australia Renal Study81; and

the Tasmanian Aborigines cardiopulmonary rehabilitation and secondary prevention

program82. The Footcare Networks in UK example is interesting given it aligns with a

74 http://www.woundsaustralia.com.au/journal/1804_02.pdf 75 https://www.asthmaaustralia.org.au/wa/education-and-training/asthma-telehealth/asthma-copd-telehealth 76 https://www.hindawi.com/journals/jdr/2016/1267215/ 77 https://www.diabetes.org.uk/professionals/professional-groups/london-footcare-network 78 https://www.aci.health.nsw.gov.au/resources/rehabilitation/rehabilitation-model-of-care/rehabilitation-

moc/care-setting6.pdf 79 http://www.wimmerapcp.org.au/wp-gidbox/uploads/2014/02/WITMITZ-G-MCMASTER-K.pdf 80 https://www.vprs.org.au/ 81http://www.health.gov.au/internet/main/publishing.nsf/content/B442C16562A8AC37CA257BF0001C9649/$File

/Final%20Report%20Central%20Australia%20Renal%20Study.pdf 82 Davey, M., Moore, W., & Walters, J. (2014). Tasmanian Aborigines step up to health: evaluation of a

cardiopulmonary rehabilitation and secondary prevention program. BMC Health Services Research, 14, 349. http://doi.org/10.1186/1472-6963-14-349

http://www.woundsaustralia.com.au/journal/1804_02.pdf

https://www.asthmaaustralia.org.au/wa/education-and-training/asthma-telehealth/asthma-copd-telehealth

https://www.hindawi.com/journals/jdr/2016/1267215/

https://www.diabetes.org.uk/professionals/professional-groups/london-footcare-network

https://www.aci.health.nsw.gov.au/resources/rehabilitation/rehabilitation-model-of-care/rehabilitation-moc/care-setting6.pdf


http://www.wimmerapcp.org.au/wp-gidbox/uploads/2014/02/WITMITZ-G-MCMASTER-K.pdf

https://www.vprs.org.au/

http://www.health.gov.au/internet/main/publishing.nsf/content/B442C16562A8AC37CA257BF0001C9649/$File/Final%20Report%20Central%20Australia%20Renal%20Study.pdf


http://doi.org/10.1186/1472-6963-14-349

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commissioning model and involves upskilling local community members and support

workers to identify and manage low risk foot complications associated with diabetes. A key

component of this model is reducing avoidable amputations and hospitalisations.

In keeping with the principles of the NHS Footcare Networks, stakeholders overwhelmingly

supported the idea of using a hub and spoke model to upskill the local workforce, raise

health literacy amongst the local community, and increase access to more special ist allied

health professionals as required. The idea was that the podiatrist based at the hub would

provide a combination of fly-in/fly-out drive-in/drive-out services to the spoke or spokes,

coupled with upskilling for the local workforce, and telehealth consults and remote support

as required.

Despite widespread support for hub-and-spoke models of care, stakeholders identified that

considered co-planning needs to occur to ensure that roles are clearly defined and there are

governance arrangements in place. In keeping with this, evidence demonstrates that hub

and spoke models are an important mechanism to improving patient care when they are well

defined, there is shared agreement on how to implement them, and a shared vision about

the benefits of the model for the community:

The healthcare industry is characterised by intensive, never-ending change

occurring on a multitude of fronts...Less efficient designs drain precious

resources and hamper efforts to deliver the best care possible to patients…

The hub-and-spoke organisation design represents and option that, when

deployed correctly, can greatly assist83.

As such, there is an opportunity for NQPHN as commissioner to work with partners to agree

on a shared vision for hub and spoke models in the region and agree on how best to

implement them in communities.

Co-design participants report that stepped models of allied health care can be supported

through:

Developing clinical pathways that clearly describe the allied health care needs of

patients;

Improving communication and information sharing between local clinicians and

visiting allied health professionals through the use of technology;

Commissioning service solutions that are evidence-based and foster collaboration

between visiting and local providers; and

Ensuring formal arrangements are put in place to clarify accountabilities and

responsibilities between providers and provider organisations in order to minimise

clinical risk.

83 Elrod, J. K., & Fortenberry, J. L. (2017). The hub-and-spoke organization design: an avenue for serving patients well. BMC Health Services Research, 17(Suppl 1), 457. http://doi.org/10.1186/s12913-017-2341-x

http://doi.org/10.1186/s12913-017-2341-x

http://doi.org/10.1186/s12913-017-2341-x

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Recommendations

1. That, in its guidance to potential commissioned providers, NQPHN requires potential


a. indicate which chronic disease priorities their proposed service solution

addresses (including but not necessarily limited to diabetes complications, COPD

and heart failure);

b. describe how their proposed service solution will focus on the specific allied

health care needs of rural, low SES and Aboriginal and Torres Strait Islander

priority population groups.

2. That NQPHN commissions a stepped model of allied health care that requires


a. deliver continuity of allied health care by integrating visiting allied health services

with local generalist providers;

b. work with local communities to identify and build the capacity of local generalist

providers to deliver continuity of allied health care;

c. indicate how the commissioned provider will utilise technology to support

continuity of allied health care; and

d. describe how the proposed stepped allied health services will be governed,

including how risk will be managed.

3. That NQPHN requires contracted agencies to monitor and report on patient

outcomes, service priorities and opportunities to further develop services and

improve access.

4. That NQPHN requires contracted agencies to establish protocols with other service

providers with a presence in the community to update patient records and transfer

information.

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NQPHN framework and roadmap for commissioning allied health

care

The following framework is proposed as a roadmap for NQPHN in commissioning allied

health care for priority chronic conditions. It is consistent with the National Framework for

Chronic Conditions.

Aim

That people in the NQPHN catchment have access to a range of high-quality, safe,

effective, and accessible allied health services that are responsive to patient needs,

integrated with the local service system and provide continuity of allied health care, and to

target priority populations

Objectives

That commissioned services are streamlined, responsive to people’s individual and cultural

needs, and delivered by a skilled workforce.

That commissioned services work cooperatively with communities and other provider

organisations to develop and implement agreed models of allied health care.

That commissioned services deliver models of allied health care are informed by evidence,

and are monitored and measured to ensure allied health services improve health outcomes

for the people who access them.

Guiding principles

The commissioning of allied health services should be guided by the following principles::

Equity of access to safe, high-quality health care irrespective of background of

personal circumstance for all residents in NQPHN;

Collaboration and partnerships – NQPHN should identify linkages with other

organisations and individuals and act upon opportunities to cooperate and partner

responsibility to achieve greater impacts than can occur in isolation;

Evidence-based – NQPHN adopts an evidence-based approach to commissioning

services, to ensure that rigorous, relevant and current evidence informs best practice

and strengthens the knowledge base to effectively prevent and manage chronic

conditions;

Person-centred - NQPHN commissions services which are person-centred and

recognise and value the needs of individuals, their carers and families, to receive

holistic care and support;

Sustainability – NQPHN ensures that strategic planning and responsible

management of resources delivers long-term improved health outcomes;

Accountability and transparency – NQPHN decisions are clear and accountable, and

achieve best value with public resources. NQPHN also requires commissioned

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providers to be accountable and transparent in working with NQPHN and local

communities.

Shared responsibility – all parties understand, accept and fulfil their roles and

responsibilities to ensure enhanced health outcomes for all Australians.

Enablers

Incremental change is likely to be required to reorient the delivery of rural allied health care

in Northern Queensland. This is represented diagrammatically below:

The following enablers can assist in achieving the vision of all people living in Northern

Queensland living healthier lives through effective prevention and management of chronic

conditions:

Governance and leadership - supports evidence-based shared decision-making and

encourages collaboration to enhance health system performance

Health workforce - a suitably trained, resourced and distributed workforce is

supported to work to its full scope of practice and is responsive to change.

Health literacy - people are supported to understand information about health and

health care, to apply that information to their lives and to use it to make decisions

and take actions relating to their health.

Research - quality health research accompanied by the translation of research into

practice and knowledge exchange strengthens the evidence base and improves

health outcomes.

Data and information - the use of consistent, quality data and real-time data sharing

enables monitoring and quality improvement to achieve better health outcomes.

Technology - supports more effective and accessible prevention and management

strategies and offers avenues for new and improved technologically driven initiatives.

Resources - adequate allocation, appropriate distribution and efficient use of

resources, including funding, to address identified health needs over the long-term.

Priority population groups

That the proposed service solutions of commissioned providers address the allied health

care needs of priority population groups, including:

rural and remote communities;

people from low socio-economic backgrounds; and

Aboriginal and Torres Strait Islander people.

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Priority chronic diseases

That the proposed service solutions of commissioned providers address allied health care

needs in NQPHN’s chronic disease priority areas, including (but not limited to) the allied

health care needs of patients with:

Diabetes complications;

COPD; and

CHF.

Commissioning criteria

That NQPHN commissioning criteria require commissioned providers to deliver allied health

service solutions that are:

evidence-based;

community driven and embedded in the community;

target priority populations and vulnerable groups;

prioritise rural and remote locations;

are multidisciplinary and team based;

support and leverage the capacity of the local health workforce;

focus on improving outcomes;

integrate with the local service system; and

have clearly articulated and established referral pathways.

Supporting service improvement through effective leadership

Stakeholders identified that NQPHN could, through its role as commissioner of allied health

care for chronic conditions, be an important agent to improve service integration in northern

Queensland communities.

Through its commissioning functions, NQPHN can improve allied health service access,

responsiveness and accountability by requiring commissioned providers to:

improve models of allied health care which improve allied health care service

continuity, whilst providing sound clinical governance and management of clinical

risk;

foster collaboration between providers;

improve communication and information sharing between providers;

demonstrate patient-centred, team-based care;

prioritise high- and at-risk patients; and

be subject to monitoring, audit and evaluation.

Stakeholders recognised that commissioning offers an opportunity for NQPHN to leverage

resources and improve how allied health services are provided to rural communities in

northern Queensland.

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NQPHN can commission for outcomes and quality of care rather than just service activity. It

can commission for new models of care that are provide safe, high quality health care in a

timely and cost-effective manner.

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Appendix 1: National Strategic Framework for Chronic Conditions

In 2017, the Australian Health Ministers’ Advisory Council developed the National Strategic

Framework for Chronic Conditions. It is the overarching policy for the prevention and

management of chronic conditions in Australia and its vision is that

All Australians live healthier lives through effective prevention and

management of chronic conditions84

The Framework shifts from a disease-specific focus (which is associated with a more

episodic model of care) to a focus on the risk factors, health determinants and multi -

morbidities that occur across chronic conditions. Risk factors can be behavioural (e.g.

smoking, insufficient physical activity), biomedical (e.g. high blood pressure), non-modifiable

(e.g. genetics), environmental (e.g. living in a remote location) and socio-economic (e.g.

employment status)85.

The Chronic Conditions Framework is designed as a resource for government and non-

government health organisations that advocate for, and provide care and education for,

people with chronic conditions and their carers and families86: As such, there may be merit

in NQPHN exploring the feasibility of reflecting the objectives, principles and enablers of the

Chronic Care Framework in their approach to commissioning chronic care services from

2018 onwards.

Definition of chronic conditions

According to the Framework chronic conditions87:

have complex and multiple causes;

may affect individuals either alone or as comorbidities;

usually have a gradual onset, although they can have sudden onset and acute

stages;

occur across the life cycle, although they become more prevalent with older age;

can compromise the quality of life and create limitations and disability;

are long-term and persistent, and often lead to a gradual deterioration of health and

loss of independence; and

while not usually immediately life threatening, are the most common and leading

cause of premature mortality.

84 Australian Health Ministers’ Advisory Council. National Strategic Framework for Chronic Conditions.

Australian Government, Canberra. 2017. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for%20Chronic%20Conditions.pdf

85 http://www.health.gov.au/internet/main/publishing.nsf/Content/chronic-disease 86 http://www.health.gov.au/internet/main/publishing.nsf/content/nsfcc 87 Australian Health Ministers’ Advisory Council. National Strategic Framework for Chronic Conditions.

Australian Government, Canberra. 2017. P. 8

http://www.health.gov.au/internet/main/publishing.nsf/content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for%20Chronic%20Conditions.pdf

http://www.health.gov.au/internet/main/publishing.nsf/content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for%20Chronic%20Conditions.pdf

http://www.health.gov.au/internet/main/publishing.nsf/Content/chronic-disease

http://www.health.gov.au/internet/main/publishing.nsf/content/nsfcc

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The Chronic Conditions Framework has three main objectives and corresponding strategic

priority areas. The objectives are:

focus on prevention for a healthier Australia;

provide efficient, effective and appropriate care to support people with chronic

conditions to optimise quality of life; and

target priority populations.

PHNs are contractually obliged to prioritise and utilise the national chronic conditions

framework.

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Appendix 2: Allied health service map for priority chronic conditions

The complete service map is provided at Attachment 1. This Appendix summarises key

findings from the analysis.

Service map methods

As previously described establishing the population-level needs of the NQPHN communities,

the first level assessment was made on the basis of three key indicators for service need

and social disadvantage. These were:

percentage of population aged over 65 years;

proportion of population who are indigenous; and

the SEIFA Index of relative social disadvantage.

These data were available at the LGA level through the PHIDU Social Health Atlas of

Australia (June 2017). It identifies 30 local government areas (LGAs) in the NQPHN. In this

publication Mareeba LGA is incorporated into the Tablelands (East)-Kuranda LGA.

The second assessment was of current population levels of chronic disease, measured by

the age standardised rates of potentially preventable hospitalisations (PPH) for the target

conditions of chronic heart failure, chronic obstructive pulmonary disease and complications

of diabetes. The total chronic PPH caseload was also included (AIHW 2017).

These data are available at the Statistical Area 3 (SA 3) level, of which there ten are wholly

within the NQPHN catchment. The sparsely populated, Outback (North) sits partially within

the catchment.

The availability of services has been determined from data promulgated or provided by

Queensland Health, Hospital and Health Services, NQPHN, NQPHN contracted services,

the Commonwealth-funded CheckUp program, Aboriginal and Indigenous Controlled Health

Services, the Royal Flying Doctor Service (RFDS), National Health Services Directory, and

professional association websites (physiotherapy, occupational therapy, social work, clinical

diabetes educators, dietitians and podiatry).

The designated workforces for each of the chronic disease conditions are as follows:

Chronic obstructive pulmonary disease – physiotherapy, exercise physiology;

Chronic heart failure – physiotherapy, exercise physiology;

Diabetes complications – diabetes education, dietetics / nutrition, podiatry; and

All chronic diseases – occupational therapy, social work.

The following tables sets grades of service and workforce availability used in this analysis.

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Table A 1: Grading of workforce availability

Grade Availability of service

1 No service identified

2 Visiting service, uncertain frequency

3 Visiting service, less than monthly

4 Visiting service, weekly - monthly

5 Visiting service available weekly

6 Visiting service available on a number of days of the week

7 Permanent, resident service

8 Permanent, resident service, frequent visiting services

9 Large permanent resident service, frequent visiting services

10 Very large permanent, resident, service, very frequent visiting services

Age standardised rates for average, annual, Medicare-rebated general practitioner visits

have also been included in the analysis.

A traffic-light approach to grade the relative impact of these factors has been used, so that a

priority for future investment can be established * (Table A 2).

Table A 2: Ranking service need and availability

Level of service need / risk

% population

65+ yrs

% indigenous population

SEIFA IRSD

GP MBS rank

SA3 rank ASR PPH

Service availability

grade

Low Need / Risk

3.2-8.5% 3.5-7.7% 961-1049 1-2 9-11 7-10

Medium Need / Risk

10.2-13.2% 8.4-26.5% 898-910 3-6 5-8 5-6

High Need / Risk

14.9-24.1% 53.3-98.1% 554-750 7-11 1-4 1-4

Identified service priorities

This analysis applies socio-demographic factors to identify communities with the highest risk

profiles for chronic disease burden and for which improved allied health care could be most

beneficial. Ten Torres and Cape Local Government Areas (LGAs) have both high

proportions of Indigenous population and relative social disadvantage.

Two other communities Palm Island and Yarrabah, also have this profile. A further two

LGAs, Torres and Cook, have a high Indigenous population percentage but without the

degree of social disadvantage of the other communities.

* In the larger, non-regional city LGAs, there are often a number of towns, which do not necessarily have the same

access to services. The data presented here represents the best service profile for the LGA.

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In addition, eight LGAs have 15% or more of their population aged over 65 years, an

independent risk factor for chronic disease.

Of the 22 LGAs identified through the three sociodemographic indicators, 19 also have a

relatively low access to general practitioner services based on age standardised, per capita,

Medicare rebates. Three LGAs, Charters Towers, Burdekin and Hinchinbrook, have

moderate access to GP services (Table A 3).

Table A 3: Priority population groups and GP services, NQPHN local government areas

Local government area

% population Indigenous

SEIFA IRSD

% of population aged 65+ years

Low GP services

rank

Lockhart River (S) X X X

Aurukun (S) X X X

Hope Vale (S) X X X

Kowanyama (S) X X X

Mapoon (S) X X X

Napranum (S) X X X

Nth Peninsula Area X X X

Pormpuraaw (S) X X X

Torres Strait Island (R) X X X

Wujal Wujal (S) X X X

Palm Island (S) X X X

Yarrabah (S) X X X

Cook (S) X X

Torres (S) X X

Cassowary Coast (R) X X

Charters Towers (R) X

Etheridge (S) X X

Tablelands (R) X X

Burdekin (S) X

Flinders (S) X X

Hinchinbrook (S) X

Richmond (S) X X

The second step in prioritising need is to apply a relative rank of potentially preventable

hospitalisations for each LGA. The third step is to rank communities according to their level

of allied health service provision.

Torres and Cape Local Government Areas

The data table identifies 10 communities (Aurukun, Hope Vale, Kowanyama, Lockhart River,

Mapoon, Napranum, Northern Peninsula Area, Pormpuraaw, Torres Strait Islands and Wujal

Wujal located in the Cape and Torres region that have both a high proportion of Indigenous

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people (>50%) and also significant levels of social disadvantage. Palm Island and Yarrabah

also have similar profiles.

In addition, these communities have high rates of potentially preventable hospital

admissions for two of the three target chronic conditions, diabetes complications, chronic

obstructive pulmonary disease and also chronic diseases overall. This is particularly

concerning as the population is on average is relatively young, with only Lockhart River

having more than 10% of the population aged over 65 years.

In broad terms the availability of the allied health workforce, whilst still patchy looks best for

the management of diabetes complications with a mix of visiting diabetes educators,

dietitian / nutritionists and podiatrists. Some communities have some access to occupational

therapists and social workers, however availability of physiotherapy and exercise physiology

services appears to be universally low (Table A 4).

Table A 4: Allied health service gaps, Torres and Cape

LGA Diab Educ

Dietetics Nutrition


Lockhart River X X

Aurukun X X

Hope Vale X X X

Kowanyama X X

Mapoon X X X

Napranum X X

Nth Pen. Area X X

Pormpuraaw X X X X

TS Island X X X X X X

Wujal Wujal X X X X X

Management of diabetes complications

The most significant workforce deficiencies appear to be for:

Diabetes education – Northern Peninsula Area and Torres Strait Islands;

Dietetics / Nutrition - Torres Strait Islands;

Podiatry – Wujal Wujal.

However only Aurukun, Lockhart River and Kowanyama have access to all three allied

health specialties on an at least weekly basis.

Management of chronic heart failure and chronic obstructive pulmonary disease

In this analysis, the availability of physiotherapy and exercise physiology in the community is

the same for both chronic heart failure (CHF) and chronic obstructive pulmonary disease

(COPD), notwithstanding that the relative rank of PPHs may be different, for instance the

Torres and Cape rank second highest for COPD, but ninth for CHF. In any case the

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availability of either profession is very low everywhere except for physiotherapy at

Napranum, which in aggregate appears to have a weekly physiotherapy service. No

exercise physiology services were identified.

The descending order of need for physiotherapy services, is:

Northern Peninsula Area;

Pormpuraaw;

Lockhart River;

Aurukun;

Torres Strait Island;

Kowanyama;

Mapoon;

Hope Vale; and

Wujal Wujal.

Occupational therapy and social work services

Four of the communities (Lockhart River, Aurukun, Kowanyama, and Northern Peninsula

Area) have at least weekly access to both occupational therapy and social work services.

Naparanum and Hope Vale have social work services visiting more frequently than weekly.

The greatest need for occupational therapy is at Torres Strait Island, then Hope Vale,

Pormpuraaw, Wujal Wujal, Mapoon and Napranum. For social work services the greatest

need is at Pormpuraaw, Torres Strait Island and Wujal Wujal.

Four communities with significant proportions of Indigenous people

Four other communities, two in the Cape and Torres region, Cook and Torres and two

others, Palm Island and Yarrabah, have a high indigenous population proportion, with the

latter two also having a high level of social disadvantage.

Cook and Torres have a high rank for diabetes complications, COPD and chronic disease

overall. Torres has relatively good access to all allied health services, with no gap identified.

Cook has a marked service gap for exercise physiology, with also less than weekly access

to podiatry and occupational therapy services.

Palm Island which is part of the Charters Towers-Ingham-Ayr SLA ranks only seventh of

eleven for diabetes complications and fifth and sixth for CHF and COPD PPH admissions

respectively. It appears to be relatively well-served for allied health services.

Yarrabah, which sits in the Innisfail-Cassowary Coast SLA, has good access to diabetes

education and dietetics / nutrition services, but has a shortfall for podiatry, physiotherapy,

exercise physiology, occupational therapy and most markedly for social work (Table A 5).

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Table A 5: Allied health service gaps in communities with high proportions of Indigenous people

LGA Diab Educ

Dietetics Nutrition


Cook X

Torres

Palm Island

Yarrabah X

Eight local government areas with substantial populations of older Australians

Eight LGAs have substantial proportions of population aged older than 65 years, of these

five have high level of chronic disease. Flinders and Richmond in fact rank first for all three

of the major chronic diseases and all total chronic disease PPHs. Etheridge ranks second

for diabetes complications, COPD and total chronic diseases and Tablelands ranks third for

diabetes and fourth for CHF. Cassowary Coast ranks third for both CHF and COPD PPHs.

Burdekin, Charters Towers and Hinchinbrook rank no higher than fifth for any of the chronic

diseases. All of these have relatively good access to allied health services, and interestingly

also to general practice. The exceptions are in Hinchinbrook and Charters Towers for

podiatry, and for exercise physiology in Tablelands and to a lesser extent occupational

therapy also in Charters Towers. Cassowary Coast does not appear to have a relative

deficiency of allied health services.

Etheridge appears to have a service gap for of all allied health services. Richmond and

Flinders also have service gaps for all the professions, but these are most marked for

physiotherapy and social work in Richmond (Table A 6).

Table A 6: Allied health services in communities with higher proportion of older people

LGA Diab Educ

Dietetics Nutrition


Cassowary Coast

Charters Towers X

Etheridge X X X X X X X

Tablelands X

Burdekin

Flinders

Hinchinbrook X

Richmond X X

Two unusual risk and service patterns

Croydon, whilst not identified as being of high risk for any of the three socio-demographic

indicators was uniquely of medium risk in all of them. In addition, it ranks second for

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diabetes complications, COPD and all chronic disease PPHs. It also has a very low access

to diabetes education, dietetics, podiatry, exercise physiology and social work.

In comparison Isaac, ranks as low risk for all the socio-demographic metrics, however has

low rates of general practice services and relatively low access to diabetes education,

dietetics, podiatry, social work and occupational therapy.

Six local government areas with low – medium risk and medium to good

access to allied health services

The other six LGAs, Cairns, Douglas, Mackay, Townsville, Weipa and Whitsunday were not

identified as either having a population at high risk or of having high rates of chronic disease

except for Weipa, which had reasonable access to the relevant allied health service.

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Appendix 3: Findings from consultation with stakeholders

This Chapter provides a synthesis of the qualitative feedback obtained in consultations,

semi-structured interviews, co-design workshops, regional chronic care reference groups,

and via written submissions. The stakeholder cohort included clinicians (GPs, GP

registrars, specialist medical practitioners, practice nurses, hospital and community

nurses, Aboriginal health workers, private and public sector allied health professionals,

service managers and administrators (Directors of Nursing, CEOs, Chief Financial

Officers, Hospital Executives, program staff), and consumers were consulted across a

broad geographical region. All feedback has been de-identified and consolidated to

maintain people’s privacy and anonymity.

Strengths of the chronic care service system

This section describes the strengths of the existing chronic care system in the NQPHN

region. In the following Section the implications for NQPHN are discussed.

Innovation and collaboration

A reported strength is that there are people working in health administration and service

provision across the system who are dedicated to improving chronic care and driving

innovation and collaboration in the region. We outline several examples of this in what

follows.

Stakeholders identified various examples of collaboration and partnerships as

mechanisms for service system improvements. One such example is the inter -agency

regional co-planning initiatives such as the Regional Health Partners Service Mapping

Report for Cape York88 which is a joint initiative between the Royal Flying Doctors

Service, Apunipima, NQPHN, and TCHHS. Of interest is that our consultants noticed a

marked increase in stakeholder feedback about the importance of partnerships and

collaboration in the Cairns and Hinterland and Torres and Cape areas. As one external

stakeholder put it:

Now is a really good time [to review how chronic care is commissioned]

as there is momentum around partnership.

Another example is the Regional eHealth Project (ReHP) driven by CHHS which aims to

improve integrated care and address challenges associated with remoteness, disparate

patient information systems, distance, and workforce turnover. The ReHP aims to deliver

an electronic health record system to support shared access to secure patient information

across 58 sites in CHHS and TCHHS which will ideally be available to non-HHS providers

in the future as well.

Similarly, stakeholders identified efforts to promote a ‘no wrong door’ approach of helping

to navigate people to the right person in the right service between Apunipima and TCHHS

as one of a series of positive initiatives stemming from partnerships. Similarly, a

88 Regional Health Partners Service Mapping for Cape York Region Report June 2017.

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collaborative approach to credentialing between RFDS, Apunipima and the HHS’s was

identified as a strength of the existing system. A key finding in consultation was that in

cases where there is a clear project for partners with defined outcomes and deliverables

to work towards and clarity around which partner was responsible for what, it is most

effective. By contrast, stakeholders took issue with cases where partners had meetings

and promising discussions but did not feel it amounted to anything concrete or tangible.

Of interest, is that, in learnings from the NHS indicate that buy in can be compromised

without tangible change initiatives providing a reason to collaborate89.

Other examples innovation and collaboration identified by stakeholders included My

Health for Life which is a joint program between Queensland Health, Diabetes

Queensland, Queensland Aboriginal and Islander Health Council, the Stroke Foundation,

the Heart Foundation, Queensland PHNs, and the Ethnic Communities Council of

Queensland90. Again here, the partnership has resulted in a concrete initiative with clearly

defined outcomes and goals.

Finally, several stakeholders identified the Community Controlled Health approach to

integrated primary care as an optimal model, particularly where there is stability of the

health workforce and established, effective relationships between service providers and

the community they care91.

Community-based, multidisciplinary approach to chronic care

A reported strength of the chronic care system is service models driven by community

members and the local workforce that involve an integrated, multidisciplinary approach to

chronic care. As one stakeholder put it:

It is about what the community needs and how can we support the

community with the different funds and service models available.

Similarly, feedback from consumers highlighted the importance of community based

shared care:

It would be good to have allied health, specialists and doctors working

together to improve communication about my care. It is so frustrating

when they don’t communicate.

We outline two examples identified by stakeholders which share interesting similarities.

First, several stakeholders identified Aboriginal health services as an exemplar of

community controlled, integrated, multidisciplinary primary care. Stakeholders highlighted

various features of an effective Aboriginal health service: team-based approach to care,

coordinates care and transports people to appointments if required, has the local GP,

89 Norman R and Robinson S. 2015 Lessons from Albion: Can Australia learn from England’s approach to primary healthcare funding? Journal of Health Organisation and Management 29 (7) pp 925-932 90 https://www.myhealthforlife.com.au/ 91 Examples of interstate health partnerships that involve effective collaboration is the Kimberley Aboriginal

Health Planning Forum. See http://www.kahpf.org.au/who-we-are/ and the Halls Creek Local Implementation Plan https://www.dss.gov.au/sites/default/files/documents/05_2012/halls_creek.pdf

https://www.myhealthforlife.com.au/

http://www.kahpf.org.au/who-we-are/

https://www.dss.gov.au/sites/default/files/documents/05_2012/halls_creek.pdf

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Indigenous Health Worker, allied health professionals, support workers and outreach

clinicians on site, and established recall and reminder systems. The virtues of this

approach to chronic care is that it is culturally appropriate, interdisciplinary, integrated,

and, when it works well, consistent with the biopsychosocial model articulated in the

National Strategic Framework for Chronic Conditions92. It also by its very nature

prioritises vulnerable and priority population groups. As one stakeholder put it:

This is comprehensive primary healthcare in the Alma Ata tradition

Other stakeholders made the point that meaningful engagement with the community and

community buy in to services is fundamental when providing chronic care regardless of

whether the service is ‘mainstream’ or Indigenous community controlled:

You cannot do chronic care without meaningful engagement with the

community – you need people to be engaged.

In keeping with the above, the second example is a community health service embedded

in and used by the local community which has established relationships with and referral

pathways to the local general practices, private allied health professionals, acute sector

and chronic care services. Two examples of this are the NQPHN funded chronic care

services provided by Mossman MPC and Burdekin Community Association93. In this kind

of service, high need, vulnerable community members are supported to access the

service through transport options, and can also access a range of complementary clinical

and support services in one location should they need to.

The virtues identified with this approach to chronic care is that there is a lower risk of

fragmenting care, the local community feels a sense of ownership over the service and

so uses and supports it, it is consistent with the national strategic priorities and evidence

regarding the need for sustainable comprehensive primary health care characterized by

multidisciplinary team approaches in rural Australian communities94. One stakeholder put

it as follows:

You need better services on the ground and a comprehensive model of

care. If providers drive or fly in and out, they are not accountable to the

community in the same way. When the organisation is community-

based, they [the service providers and funded organisations] have to

face the community daily and that makes a difference.

Despite widespread support for community-driven and embedded service models, some

stakeholders made the point that merely co-locating services in a community hub or

health service is a necessary, not sufficient condition for integrated chronic care. This is

92https://www.health.gov.au/internet/main/publishing.nsf/Content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for%20Chronic%20Conditions.pdf

94 Tham r, Humphreys J, Kinsman L, Buykx P, Asaid A, Tuohey K. 2011. Study protocol: Evaluating the

impact of a rural Australian primary health care service on rural health. BMC Health Services Research 2011 11:52

https://www.health.gov.au/internet/main/publishing.nsf/Content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for%20Chronic%20Conditions.pdf

https://www.health.gov.au/internet/main/publishing.nsf/Content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for%20Chronic%20Conditions.pdf

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consistent with research on co-locating services in the absence of a recognition of the

value of shared, integrated care, territorialism and unwillingness to engage in inter-

professional practice may threaten integrated care95. As such, there is a need for

NQPHN’s approach to commissioning to include mechanisms to ensure stakeholders are

providing an integrated service and that, where possible, service models involve investing

in the local workforce and prioritising consumer co-design.

Hub and spoke models of care

Many stakeholders identified hub and spoke models as a promising model of chronic care

for the region96 on the proviso that the local workforce is engaged in developing and

implementing the service model. The focus on hub and spoke models was in response to

widespread recognition that the health workforce is limited, there is a significant

geographical area to service, and an imperative to maximise opportunities and service

provision with limited resources (see section 4.2 for more detail).

Various examples of hub and spoke models were discussed during consultation. These

included the Footcare Networks in the UK97; outreach rehabilitation programs for patients

in rural and remote NSW98; Wimmera Cardiac Rehabilitation Hub and Spoke Telehealth

Model99, Victorian Paediatric Rehabilitation Service100; Central Australia Renal Study101;

and the Tasmanian Aborigines cardiopulmonary rehabilitation and secondary prevention

program102. The Footcare Networks in UK example is interesting given it aligns with a

commissioning model and involves upskilling local community members and support

workers to identify and manage low risk foot complications associated with diabetes. A

key component of this model is reducing avoidable amputations and hospitalisations.

In keeping with the principles of the NHS Footcare Networks, stakeholders

overwhelmingly supported the idea of using a hub and spoke model to upskill the local

workforce, raise health literacy amongst the local community, and increase access to

more specialist allied health professionals as required. The idea was that the podiatrist

based at the hub would provide a combination of fly-in/fly-out drive-in/drive-out services

to the spoke or spokes, coupled with upskilling for the local workforce, and telehealth

consults and remote support as required. How this might work in practice is the podiatrist

does a face-to-face clinic, sets aside time to provide training on diabetic foot screening

and managing low risk foot care while on sight, and agrees on a triaging system where

95 Lawn, S. Lloyd A, King A et al. 2014. Integration of primary health services: being put together does not mean they will work together. BMC Reseahch Notes 2014. 7:66.

96 Briefly, the hub and spoke model is where a larger service provider organisation (hub) provides more limited services to smaller organisations (spokes) and has referral pathways in place for patients at the spokes to receive more intensive support at the hub if required.

97 https://www.diabetes.org.uk/professionals/professional-groups/london-footcare-network 98 https://www.aci.health.nsw.gov.au/resources/rehabilitation/rehabilitation-model-of-care/rehabilitation-

moc/care-setting6.pdf 99 http://www.wimmerapcp.org.au/wp-gidbox/uploads/2014/02/WITMITZ-G-MCMASTER-K.pdf 100 https://www.vprs.org.au/ 101http://www.health.gov.au/internet/main/publishing.nsf/content/B442C16562A8AC37CA257BF0001C9649/$

File/Final%20Report%20Central%20Australia%20Renal%20Study.pdf 102 Davey, M., Moore, W., & Walters, J. (2014). Tasmanian Aborigines step up to health: evaluation of a

cardiopulmonary rehabilitation and secondary prevention program. BMC Health Services Research, 14, 349. http://doi.org/10.1186/1472-6963-14-349

https://www.diabetes.org.uk/professionals/professional-groups/london-footcare-network



http://www.wimmerapcp.org.au/wp-gidbox/uploads/2014/02/WITMITZ-G-MCMASTER-K.pdf

https://www.vprs.org.au/



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local providers can send photos and make referrals between outreach clinics if they

encounter a high-risk foot. Stakeholders identified various benefits with this kind of

model:

increasing access to timely care for local patients

reducing the risk of burnout associated with travelling to provide all clinics face-to-

face

upskilling local workforce to provide low risk care between visits

maximising on the specialist workforce and minimising the risk that visiting allied

health professionals are seeing people who could be seen by local service

providers and / or support workers

maximising on the local support and clinical workforce

increasing professional development and support for local workforce which may in

turn improve professional satisfaction

increased likelihood of servicing patients who need it most due to local knowledge

of community.

Despite widespread support for hub-and-spoke models of care, stakeholders identified

that considered co-planning needs to occur to ensure that roles are clearly defined and

there are governance arrangements in place. In keeping with this, evidence demonstrates

that hub and spoke models are an important mechanism to improving patient care when

they are well defined, there is shared agreement on how to implement them, and a

shared vision about the benefits of the model for the community:

The healthcare industry is characterised by intensive, never-ending

change occurring on a multitude of fronts...Less efficient designs drain

precious resources and hamper efforts to deliver the best care possible

to patients… The hub-and-spoke organisation design represents and

option that, when deployed correctly, can greatly assist103.

As such, there is an opportunity for NQPHN as commissioner to work with partners to

agree on a shared vision for hub and spoke models in the region and agree on how best

to implement them in communities.

Telehealth

Stakeholders identified telehealth as a strength of the current chronic care system and

many identified the need to increase uptake in telehealth where there is the infrastructure

and connectivity to do so. Stakeholders also saw telehealth as a way to enhance a hub

and spoke service model by providing telehealth consults between outreach visits.

103 Elrod, J. K., & Fortenberry, J. L. (2017). The hub-and-spoke organization design: an avenue for serving patients well. BMC Health Services Research, 17(Suppl 1), 457. http://doi.org/10.1186/s12913-017-2341-x

http://doi.org/10.1186/s12913-017-2341-x

http://doi.org/10.1186/s12913-017-2341-x

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Although there was agreement that telehealth cannot be used to replace face-to-face

service delivery altogether, stakeholders overwhelmingly agreed that telehealth is an

important aspect of chronic care service provision to rural and remote locations.

Stakeholders also cautioned that in areas where telehealth is new or uptake is currently

low, there is a need for a change management approach to support the local community

and clinicians to understand the opportunities with telehealth. Stakeholders reported that

telehealth works best where the following is in place104:

effective relationships between patients, staff at the location where the telehealth

is provided (if applicable), and the clinician providing telehealth services e.g.

patient has already had a face-to-face consult and has a rapport with the clinician

there is the infrastructure, connectivity and bandwidth in place and / or people can

access telehealth on their home devices

there is engagement with the local community to assess whether the distance to

access telehealth is close enough for them not to choose to travel further for a

face-to-face

there is a local service coordinator/health worker to help set up the room, book

clinics, and support patients if required

where required there is transport for higher need patients to come to the clinic

the local community and local service providers know about the service and

regard it as valuable.

Although views were mixed on whether patients who currently did not use telehealth

would do so in the future, overall our consultants observed that stakeholders who had

used telehealth were more supportive of it, while those who had not were less so. There

were also misconceptions amongst some allied health professionals about telehealth. For

example, a few clinicians who provide support with self-management and coaching for

weight loss and chronic disease management thought telehealth could not work for their

services. However, research demonstrates high levels of consumer satisfaction with

telehealth and no significant differences in outcomes between face-to-face and telehealth

consults105.

104 See https://www.sarrah.org.au/sites/default/files/docs/allied_health_and_telehealth_final_ -_19.10.12.pdf for a more detailed discussion of telehealth enablers with allied health service provision in rural Australia.

105Representative her: Australian College of Rural and Remote Medicicne 2016. Effectiveness of Telehealth Consultations: Clinical Conditions – What is the evidence for the effectiveness of telehealth; Bashshur, R. L., Shannon, G. W., et al. (2014). The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management. Telemedicine Journal and E-Health, 20(9), 769–800; Raven M, Bywood O. 2013. Allied health video consultation services. PCHRIS Policy Issues Review. Adelaide: Primary Health Care Research and Information Service, Allen, J. V., Davis, A. M., & Lassen, S. (2011). The use of Telemedicine in Pediatric Psychology: Research Review and Current Applications. Child and Adolescent Psychiatric Clinics of North America, 20(1), 55–66.

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Examples of effective telehealth discussed in the context of consultations included: Tele-

ICU106, Tele-Derm National107, the store-and-forward telehealth systems to assist in

managing diabetic foot ulcers pilot in Queensland108, the Asthma and COPD Telehealth

Service for Country WA109, and hub and spoke diabetes retinopathy screening enhanced

by telemedicine technology110.

Feedback from consultations suggests there are opportunities for NQPHN to work with

local communities and service providers to increase understanding about how telehealth

can be used to improve access to chronic care services. It would be worth bearing in

mind the following feedback from stakeholders:

Telehealth is supplementary and depends on relationships [with

providers, hosts, clients]

The best models are where people can access it at home and have the

skills, capacity and bandwidth to do so…or when you get the provider to

dial into the station.

Some organisations (particularly in the Torres and Cape) have

telehealth and like to use it though they are dependent on the health

workers on the islands to coordinate it.

For it to work you need service coordination with someone to organise

the patient, the software and the system.

Given the findings above, NQPHN should look at ways to work with stakeholders to

support local service coordination for telehealth, as well as supporting the local workforce

to ensure patients who would benefit from telehealth can access it. There would also be

merit in NQPHN prioritising chronic care service models that include telehealth, as long

as consideration has been given by prospective service providers about how to

implement a model of care that includes telehealth in the region in question. This will

require engaging the local community and chronic care workforce.

Other issues raised

Some of the additional feedback from stakeholders regarding the strengths of the existing

chronic care system included:

the CheckUP regional coordination model where a coordinator is located in and

responsible for building relationships in a region, is well-regarded and seen by a

broad range of stakeholders as a promising model of program administration.

106 https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-16-Guidelines-on-the-Use-of-Telemedicine-in-Intensive-Care.pdf

107 http://www.acrrm.org.au/search/find-online-learning/details?id=1019 108 http://www.woundsaustralia.com.au/journal/1804_02.pdf 109 https://www.asthmaaustralia.org.au/wa/education-and-training/asthma-telehealth/asthma-copd-telehealth 110 https://www.hindawi.com/journals/jdr/2016/1267215/




http://www.acrrm.org.au/search/find-online-learning/details?id=1019

http://www.woundsaustralia.com.au/journal/1804_02.pdf

https://www.asthmaaustralia.org.au/wa/education-and-training/asthma-telehealth/asthma-copd-telehealth

https://www.hindawi.com/journals/jdr/2016/1267215/

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the most valuable use of the NQPHN-funded chronic care services is where

vulnerable, high-need patients who could not otherwise afford services are

prioritised and have access to them.

there is a considerable support workforce across the NQPHN catchment that

tends to be under-utilised. This includes, but is not limited to, Indigenous Health

Workers, Health and Community Care (HACC) support workers, outreach workers,

and volunteers.

Identified Chronic Care Service System Needs

What follows is an overview of the main service and system gaps identified during

consultations, as well as stakeholder views on how NQPHN can assist in redressing

some of the identified issues through commissioning. Table A 7provides a snapshot of

stakeholder views on the chronic care service system needs and suggestions regarding

the role of NQPHN in addressing them111.

111 There is some overlap in the themes and the suggestions put forward by stakeholders as to how NQPHN

might address them.

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Table A 7: Stakeholder perspectives on NQPHN role in chronic care service system

Theme There is a need for NQPHN to

Decrease destructive competition and uncertainty

• Ensure tender processes promote collaboration and constructive competition i.e. competition that fuels improved services for local communities

• Promote co-commissioning and reward consortium tenders where appropriate

• Continue to communicate the rationale for commissioning and purpose of NQPHN as a commissioning organisation to stakeholders

• Prioritise tenders based on their ability to demonstrate local knowledge, relationships, referral pathways and capacity building,

• Put strategies in place to accommodate f lexible and holistic services best positioned to address chronic care needs at the local community level

• Facilitate communication and collaboration between partners through co-planning how best to commission (and co-commission) services to the region

• Ensure it provides sufficient notice, information and clarity around commissioning and tender processes

• Clarify the goals of tender processes e.g. chronic care funding aims to prioritise MDT services that increase access to care for people in rural, remote and Indigenous communities who have or are at risk from COPD, CVD, Diabetes and / or associated complications.

Reduce fragmentation of chronic care services and improve coordination of care

• With support from partners, take a leadership role in facilitating communication between the acute sector, the primary care sector and the community sector

• Consider projects focused on improving transfers of care between the acute and community sector

• Prioritise tenders that demonstrate effective local relationships, services are integrated with the local service system, and there are established referral pathways

• Prioritise tenders that include communication and support strategies to support the local community and workforce, and processes to ensure services are coordinated.

• Prioritise tender that include clearly defined roles for outreach and local service providers.

• Recognise that short-term contracts increase the risk of workforce attrition, uncertainty and dissatisfaction and put strategies in place to mitigate that risk

• Promote uptake in Health Assessments and Chronic Disease Care Plan MBS items in general practices, particularly Aboriginal and Torres Strait Islander Assessments

• Look at opportunities to leverage off Health Pathways Program to reduce fragmentation

• Prioritise tenders that demonstrate integration between the private and public chronic care service systems

Improve role delineation and governance across the region

• Work with stakeholders to formalise and standardise role delineation and governance with respect to regional chronic care services

• Prioritise tenders that demonstrate clear role delineation and governance arrangements

• Prioritise tenders that demonstrate established lines of accountability and processes to ensure quality and safety

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Theme There is a need for NQPHN to

• Prioritise tenders that demonstrate an understanding of service scope, service requirements, and processes to streamline transfers of care

• Clarify the role, scope, nature and purpose of partnerships • Work with partners and stakeholders to develop a long-term,

system-wide vision for chronic care in Northern Queensland

Improve consumer-directed care and access

• Continue to involve consumers in co-designing and evaluating chronic care services

• Prioritise rural and remote chronic care services • Prioritise chronic care services that are locally embedded and

involve a team-based, MDT approach • Prioritise services for vulnerable population groups • Leverage off partnerships and strategic relationships to improve

access to transport support for patients who need it • Priortise tenders that demonstrate services are environmentally

and culturally accessible for vulnerable consumers / priority populations

• Prioritise tenders that maximise telehealth and leverage off the local workforce to reduce unnecessary travel for consumers

• Prioritise tenders that involve transport support for consumers in more remote locations

• Partner with Aboriginal and Torres Strait Islander organisations to increase uptake in cultural awareness and respect training across the region

• Prioritise services that are consumer-directed and treat consumers as equal partners in shared care

Improve workforce capability and capacity

• Continue to work with partners and stakeholders to identify opportunities to provide targeted training and support for primary care staff

• Work with rural and remote health care providers to identify and support training needs focused on the complexities of providing chronic care in rural and remote locations.

• Prioritise tenders that support and involve the local workforce • Prioritise tenders that demonstrate relationships between primary

and tertiary sectors and / or between specialist providers and the generalist support workforce

• Increase efforts to support the local general practice workforce to do high-quality health assessments and chronic care plans that link patients in to a team of health care professionals

• Work with partners to co-commission initiatives that address the increasingly complex care needs of people with chronic conditions in rural and remote areas

• Support service models that draw on the general workforce in regional communities e.g. Aboriginal health workers, physician assistants, nurse practitioners, nurses.

• Prioritise tenders that include service models where providers can work to their full scope of practice

• Avoid commissioning chronic care services where providers are clinically isolated and there is single person dependency

Many stakeholders identified opportunities for NQPHN to play a more active leadership

role in facilitating communication and collaboration between key stakeholder groups to

improve integration and coordination of care. Overall, stakeholders saw commissioning

as more of an opportunity than a challenge.

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Challenges and opportunities with commissioning

Several stakeholders saw it as a challenge that NQPHN is still establishing itself as a

commissioning organisation and communicating what that means to its stakeholders. As

one stakeholder put it:

As a commissioning entity, the PHN is investing in life expectancy and

avoidable hospitalisations. This is a big shift from contracting allied

health services.

Others made the point that commissioning will require unprecedented leadership, vision

and sustained change management. Stakeholders saw the conceptual and cultural shift

from outputs to outcomes as something that would need to be change managed by

NQPHN:

There is a need to commission for outcomes rather than outputs…it’s a

change process: changing the culture to outcomes thinking. That is not

easy but it’s exciting and long overdue.

Despite some confusion about the nature of commissioning and stakeholders identifying

room for NQPHN to build on communicating and clarifying its roles as a commissioner,

most stakeholders regarded commissioning as an opportunity and a lever for positive

change in the region. Some of the specific opportunities identified in consultations

include:

embedding a culture where market competition and tendering for funding means

services are not funded in the future just in virtue of being funded in the past, and

collaboration, consumer-directed care and innovation such as co-commissioning

are the norm. As one stakeholder said:

In an ideal world, there would be more formalised mechanisms where

we can co-commission to get more efficiencies and leverage off each

other to complement the service system.

An example discussed in consultation was looking at opportunities to commission

across program funds where doing so optimises outcomes for communities e.g.

looking at opportunities for service providers in high need communities to tender

for a combination of Integrated Team Care, Mental Health commissioning and

Chronic care, to support a holistic service. Many regarded it as problematic that

within and across organisations, funding programs tend to be treated as distinct

siloes when they all ultimately aim to support improved health outcomes and

access to health care. That said, there was recognition that the fragmented nature

of existing program funds was in large part due to how the Commonwealth and

state governments fund health.

using commissioning as a lever to monitor and evaluate services through a more

robust procurement process. One stakeholder put it as follows:

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Contract management with partnerships and a layer of consequence

that holds us all to account, including turning up to meetings to co-plan

and evaluate what we are doing.

another opportunity identified with commissioning was using it as a mechanism

to measure whether clinical interventions are having a positive impact on health

behaviours:

You can measure HbA1C…but it still doesn’t tell you whether the patient

is making better life choices or understands how to manage their

conditions. It would be great to look at ways to measure that.

In keeping with feedback from stakeholders, evidence supports the need to adopt a

change management approach to commissioning which includes meaningful engagement

with priority communities to ensure outcomes are appropriate112. It also supports the need

for clear, targeted communication with all stakeholders.

A related point, and as NQPHN have already identified, given existing service providers

have been funded to provide chronic care services for many years, there is a need for

unambiguous and timely information about what the transition to commissioning chronic

care means for individual service providers and communities.

Summary

Overall, stakeholder identified a range of strengths and weaknesses of the chronic care

system in Northern Queensland, as well as opportunities for NQPHN to commission

services that can help overcome some of the identified systems gaps.

The findings above, while representative of a cross-section of stakeholders, need to be

treated with caution. It is feasible that the consumers involved were not representative of

consumers in the NQPHN region more broadly given they were already relatively

invested in the health service system. Further, it cannot be ruled out that those consulted

provided less critical feedback than they might otherwise due to fear that it could

adversely affect local clinicians and services.

112 Australian Government Department of Health. PHN Commissioning. Planning in a commissioning environment: a Guide June 2016 Available: http://www.health.gov.au/internet/main/publishing.nsf/Content/PHNCommissioningResources and Shortall S, and Alston M. 2016. ‘To Rural Proof or Not to Rural Proof: A Comparative Analysis’ Politics & Policy 44:1 pp35-55 .

http://www.health.gov.au/internet/main/publishing.nsf/Content/PHNCommissioningResources

REVIEW OF CHRONIC CARE SERVICES

IN NORTHERN QUEENSLAND

ATTACHMENT 1: SERVICE MAPPING

of 23

Contents

Mapping Northern Queensland health needs ......................................................................................... 3

Communities most affected by limited health care .................................................................................. 3

Burden of the priority diseases............................................................................................................... 4

Figures

Figure 1. Diabetes – disease level and distribution of diabetes education workforce .............................. 6

Figure 2. Diabetes – disease level and distribution of dietetics and nutritionist workforce ....................... 8

Figure 3. Diabetes – disease level and distribution of podiatry workforce ............................................. 10

Figure 4. Chronic heart failure – disease level and distribution of physiotherapy workforce .................. 12

Figure 5. Chronic heart failure – disease level and distribution of exercise physiology workforce ......... 14

Figure 6. COPD – disease level and distribution of physiotherapy workforce ........................................ 16

Figure 7. COPD – disease level and distribution of exercise physiology workforce ............................... 18

Figure 8. All chronic conditions – disease level and disbtribution of occupational therapy workforce .... 20

Figure 9. All chronic conditions – disease level and distribution of social workers ................................ 22

Tables

Table 1: Diabetes disease burden + availability of diabetes education workforce by LGA ....................... 7

Table 2: Diabetes disease burden + availability of dietitian/nutritionist workforce by LGA ....................... 9

Table 3: Diabetes disease burden + availability of podiatry workforce by LGA ...................................... 11

Table 4: CHF disease burden + availability of physiotherapy workforce by LGA ................................... 13

Table 5: CHF disease burden + availability of exercise physiology workforce by LGA .......................... 15

Table 6: COPD disease burden + availability of physiotherapy workforce by LGA ................................ 17

Table 7: COPD disease burden + availability of exercise physiology workforce by LGA ....................... 19

Table 8: All chronic disease burden + availability of occupational therapy workforce by LGA ............... 21

Table 9: All chronic disease burden + availability of social workers by LGA .......................................... 23

About the Service Maps

These maps provide an overview of the allied health services that are available for people

living with chronic diseases in rural and remote areas of Northern Queensland.

This work has been undertaken by KP Health on behalf of the Northern Queensland

Primary Health Network.

The maps have been developed based on available service system and administrative data

made available to KP Health.

Research and data collection methods are described in the full report “Review of Chronic

Care Services in Northern Queensland”. KP Health Pty Ltd. December 2017.

of 23

Mapping Northern Queensland health needs

These maps provide an overview of the allied health services that are available for people living

with chronic diseases in Northern Queensland.

Each map shows chronic disease as shaded areas, overlayed with coloured circles to represent

the availability of one specific allied health service.

Priority Chronic Diseases

Three chronic diseases cause many potentially preventable hospitalisations (PPH) in Northern

Queensland. They are:

chronic heart failure (CHF)

chronic obstructive pulmonary disease (COPD)

complications of diabetes

We have identified these three diseases as priority areas for commissioning. These are

identified in the NQPHN comprehensive needs assessment as highly prevalent in the NQPHN

areas of responsibility.

Priority Population Groups

Three priority population groups were identified in the NQPHN comprehensive needs assessment. These are people who experience poor health from chronic disease much more than usual. These groups are:

rural and remote communities

Aboriginal or Torres Strait Islanders

people from low socio-economic backgrounds.

Allied health care is important in rural communities

Allied health care is essential to help improve health outcomes for people with chronic disease.

Allied health professionals work to prevent, diagnose and treat a range of conditions and illnesses

and often work within a multidisciplinary health team to provide the best outcomes for people.

The allied health professions that are most relevant to these chronic diseases are:

Condition Allied health areas

Diabetes Diabetes education | Dietetics | Podiatry

Chronic Heart Failure Physiotherapy | Exercise Physiology

Chronic Obstructive Pulmonary Disease Physiotherapy | Exercise Physiology

All chronic disease Occupational Therapy | Social work

‘Allied Health’ is a term used to describe the broad range of health professionals who are not

doctors, dentists or nurses. Allied health professionals include, for example, physiotherapists,

podiatrists and social workers.

of 23

Communities most affected by limited health care

The shaded areas on the maps show which communities were the most affected by chronic

disease conditions and where improved allied health care could be most beneficial. To identify

these communities, we looked at three things:

1. The risk profile of the community

We measured the proportion of people in each community who:

live in rural or remote communities

are Aboriginal or Torres Strait Islanders

have socio-economic disadvantage

have low levels of access to general practictioner services.

2. The levels of chronic disease

We measured the amount of potentially preventable hospitalisations (PPH) in each area

that were related to:

chronic heart failure (CHF)

chronic obstructive pulmonary disease (COPD)

complications of diabetes

all conditions combined.

3. The availability of allied health services

We measured availability of the following types of allied health services for each of the

chronic disease conditions:

physiotherapy and exercise physiology for COPD

physiotherapy and exercise physiology for CHF

diabetes education, dietitics/nutrition, and podiatry for diabetes complications

occupational therapy and social work for all chronic diseases combined.

Services are graded from 1 to 10 based on the workforce availability

Each service was given a grade, or score, from 1 to 10, based on how available the service

was in each area. These grades are described in more detail below:

Grade Service availability

1 No service identified

2 Visiting service, uncertain frequency

3 Visiting service, less than monthly

4 Visiting service, weekly – monthly

5 Visiting service, available weekly

6 Visiting service, available on number of days of the week

7 Permanent, resident service

8 Permanent, resident service, frequent visiting services

9 Large permanent, resident service, frequent visiting services

10 Very large permanent, resident service, very frequent visiting services

of 23

Burden of the priority diseases

Diabetes

Chronic Heart Failure

Chronic Obstructive Pulmonary Disease

Abbreviations

CHF Chronic Heart Failure

COPD Chronic Obstructive Pulmonary Disease

LGA Local Government Area

PPH Potentially Preventable Hospitalisations

People with diabetes have an increased risk of developing many serious health

problems. In Australia diabetes is a leading cause of cardiovascular disease,

blindness, kidney failure, and lower limb amputation. Diabetes is estimated to cost

the Australian economy at least $14 billion every year.

Chronic heart failure affects about half a million Australians and costs our economy

$1 billion annually. General practitioners, together with heart failure nurses and allied

health professionals, play a key role in managing this condition.

Over 310,000 Australians aged over 55 years have COPD. COPD is the second

commonest cause of avoidable hospital admissions in Australia and in 2012 was the

fifth leading cause of death in Australia, accounting for 4% of all deaths. Overall there

were 9,633 potentially preventable bed days linked to this disease. The trend appears

to be worsening from 2013–2016.

Complications from Diabetes

Page 6 of 23

Distribution of the diabetes education workforce

Figure 1. Diabetes – disease level and distribution of diabetes education workforce

One community reported receiving visiting diabetes educator services

from two different organisations. … they did not know the other provider

was delivering care in the same community, and therefore do not share

information, communicate with one another or plan their services

accordingly.

Finding from review of chronic care services in Northern Queensland

Key


Low

Medium

High

Disease burden

High

Medium

Low

Key Points

Our analysis

highlighted 19 local

government areas with

priority populations.

Northern Peninsula

Area and Torres Strait

Island are the most

deficient in Diabetes

Education.

Ten communities in

the Torres and Cape

regions have a high

proportion of

indigenous people and

significant levels of

social disadvantage.

Palm Island and

Yarrabah have similar

profiles.


Page 7 of 23

Table 1: Diabetes disease burden + availability of diabetes education workforce

by LGA

Disease Burden Local Government Area Diabetes Educators

1 Flinders

Richmond

2

Croydon

Etheridge

Nth Peninsula Area

Torres Strait Island

Hope Vale

Mapoon

Wujal Wujal

Lockhart River

Pormpuraaw

Aurukun

Cook

Kowanyama

Napranum

Torres

Weipa

3 Tablelands

4 Douglas

5 Townsville

6 Cairns

7

Palm Island

Burdekin

Charters Towers

Hinchinbrook

8 Whitsunday

9 Yarrabah Cassowary Coast

10 Mackay

11 Isaac Notes 1 Disease burden by SA3. Ranked 1 (High) – 11 (Low) 2 Service availability by LGA. Scored 1 (No available service) – 10 (Comprehensive available service)

Australia-wide there is a chronic shortage of allied health professionals

working in rural and remote locations.

– Australian Institute of Health and Welfare. Allied health workforce 2012


Page 8 of 23

Distribution of the dietitics and nutritionist workforce

Figure 2. Diabetes – disease level and distribution of dietetics and nutritionist workforce

Maintaining blood glucose levels, blood pressure, and cholesterol at or

close to normal can help delay or prevent diabetes complications.

Therefore, people with diabetes need regular monitoring and

comprehensive, multidisciplinary management.


Key


Low

Medium

High

Disease burden

High

Medium

Low

Key Points


is the most deficient

in Dietetics.

The NQPHN

catchment has a

much higher rate of

preventable

hospitalisations for

diabetes

complications than

the national

average.

Management of

diabetes

complications is

multidisciplinary and

needs to be

comprehensive to

be effective.


Page 9 of 23

Table 2: Diabetes disease burden + availability of dietitian/nutritionist workforce

by LGA

Disease Burden t Local Government Area Dietitians / Nutritionists

1 Flinders

Richmond

2

Croydon

Etheridge


Mapoon

Nth Peninsula Area

Pormpuraaw

Aurukun

Kowanyama

Wujal Wujal

Cook

Hope Vale

Lockhart River

Napranum

Torres

Weipa

3 Tablelands

4 Douglas

5 Townsville

6 Cairns

7

Burdekin

Palm Island

Charters Towers Hinchinbrook

8 Whitsunday

9 Yarrabah Cassowary Coast

10 Mackay


“There are lots of benefits as I can see high-need patients for an hour and

get to know them and their conditions. I get to see people who’ve had

diabetes for years and never seen a dietitian or a diabetes nurse educator. ”

A service provider who receives chronic care funding


Page 10 of 23

Distribution of the podiatry workforce

Figure 3. Diabetes – disease level and distribution of podiatry workforce

Key Points

Wujal Wujal has the

greatest deficiency

in the Podiatry

workforce.

Only Aurukun,

Lockhart River and

Kowanyama have

access to all three

diabetes-specifice

allied health

specialties on a

weekly basis.

Podiatry services

are provided to

avarying extent by a

mix of state

government,

contracted and

private providers

Personal carers, Aboriginal health workers and nurses can, with the

support of allied health specialists, provide less complex components of a

patient’s allied health care needs and appropriately refer more complex

patients to visiting allied health specialist providers, making better use of

the visiting providers’ expertise and available time.


Key


Low

Medium

High

Disease burden

High

Medium

Low

Key


Low

Medium

High

Disease burden

High

Medium

Low


Page 11 of 23

Table 3: Diabetes disease burden + availability of podiatry workforce by LGA

Disease Burden Local Government Area Podiatry Workforce

1 Flinders

Richmond

2

Croydon

Etheridge

Wujal Wujal

Cook

Hope Vale

Mapoon

Napranum

Nth Peninsula Area

Pormpuraaw


Lockhart River

Weipa

Aurukun

Kowanyama

Torres

3 Tablelands

4 Douglas

5 Townsville

6 Cairns

7

Hinchinbrook

Charters Towers

Palm Island

Burdekin

8 Whitsunday

9 Yarrabah

Cassowary Coast

10 Mackay


Individual service providers reported that the funding can be so limited,

that the benefits of providing the service can be outweighed by the

administrative burden and loss of business opportunity.

–Interview of service providers; Review of chronic care services in Northern Queensland


Page 12 of 23

Distribution of the physiotherapy workforce

Figure 4. Chronic heart failure – disease level and distribution of physiotherapy workforce

Key Points

Physiotherapy

services are also

provided to varying

extent by a mix of

state government,

contracted and

private providers.

Increasing access

to allied health care

is an important

component of

improving regional,

rural and remote

health outcomes

Availability of

physiotherapy

services appears to

be universally low,

except for

Napranum.

Some providers are still reporting on seeing patients from outlying areas

which makes it look as if the providers are doing outreach. However, in

some cases patients are travelling, not the clinicians.


Key


Low

Medium

High

Disease burden

High

Medium

Low


Page 13 of 23

Table 4: CHF disease burden + availability of physiotherapy workforce by LGA

Disease Burden Local Government Area Physiotherapy Workforce

1 Richmond

Flinders

2 Douglas

3 Yarrabah

Cassowary Coast

4 Tablelands

5

Palm Island

Burdekin

Charters Towers

Hinchinbrook

6 Cairns

7 Whitsunday

8 Mackay

9

Nth Peninsula Area

Pormpuraaw

Aurukun

Lockhart River


Croydon

Etheridge

Kowanyama

Hope Vale

Mapoon

Wujal Wujal

Napranum

Cook Torres Weipa

10 Townsville

11 Isaac

Notes 1 Disease burden by SA3. Ranked 1 (High) – 11 (Low) 2 Service availability by LGA. Scored 1 (No available service) – 10 (Comprehensive available service)

Service providers repeatedly made the point that outreach is time consuming,

inefficient, and ultimately results in a poorer quality of service for patients (as

the clinic times are shorter and the rooms typically do not have all the

equipment and resources required).

–Interview of service providers; Review of chronic care services in Northern Queensland


Page 14 of 23

Distribution of the exercise physiology workforce

Figure 5. Chronic heart failure – disease level and distribution of exercise physiology workforce

Key Points

Napranum has no

exercise physiology

services.

Cook has a marked

service gap for

exercise physiology,

with also less than

weekly access to

podiatry and

occupational

therapy services.

Recruitment of the

workforce of

registered health

practitioners in the

field of exercise

physiology (and

others) has been

challenging.

Key


Low

Medium

High

Disease burden

High

Medium

Low

NQPHN can, through commissioning, reorient allied health service

delivery to improve continuity of allied health care and leverage the

capacity of the generalist workforce to deliver services.



Page 15 of 23

Table 5: CHF disease burden + availability of exercise physiology workforce by

LGA

Disease Burden Local Government Area Exercise Physiology Workforce

1 Flinders

Richmond

2 Douglas

3 Yarrabah

Cassowary Coast

4 Tablelands

5

Charters Towers

Palm Island

Burdekin

Hinchinbrook

6 Cairns

7 Whitsunday

8 Mackay

9

Aurukun

Cook

Croydon

Etheridge

Hope Vale

Kowanyama

Lockhart River

Mapoon

Napranum

Nth Peninsula Area

Pormpuraaw

Wujal Wujal


Torres

Weipa

10 Townsville


Others made the point that commissioning will require unprecedented

leadership, vision and sustained change management. Stakeholders saw the

conceptual and cultural shift from outputs to outcomes as something that would

need to be change managed by NQPHN.

Stakeholder interviews; review of chronic care services in Northern Queensland


Page 16 of 23

Distribution of the physiotherapy workforce

Figure 6. COPD – disease level and distribution of physiotherapy workforce

Diabetes complications, chronic heart failure (CHF) and chronic

obstructive pulmonary disease (COPD) contribute substantially to the

large potentially preventable hospitalisations burden in Northern

Queensland [and] are amenable to improved outcomes through the

provision of high-quality allied health care.


Key


Low

Medium

High

Disease burden

High

Medium

Low

Key Points

Having an allied

health professional

in an area does not

guarantee that the

community’s highest

priority health needs

are being met or

that the service is

accessible, effective

and good quality.

Availablity of

physiotherapy and

exercise physiology

services is very low,

except for

Napranum which

appears to have a

weekly

physiotherapy

service.


Page 17 of 23

Table 6: COPD disease burden + availability of physiotherapy workforce by LGA

Disease Burden Local Government Area Physiotherapy Workforce

1 Richmond

Flinders

2

Nth Peninsula Area

Pormpuraaw

Aurukun

Lockhart River


Croydon

Etheridge

Kowanyama

Hope Vale

Mapoon

Wujal Wujal

Napranum

Cook

Torres

Weipa

3 Yarrabah

Cassowary Coast 4 Douglas

5 Tablelands

6

Palm Island

Burdekin Charters Towers Hinchinbrook

7 Townsville

8 Cairns

9 Mackay

10 Isaac

11 Whitsunday


Patients with COPD need a plan of care with management goals, including

self-management, and the involvement of multidisciplinary team members


Page 18 of 23

Distribution of the exercise physiology workforce

Figure 7. COPD – disease level and distribution of exercise physiology workforce

Key Points

Torres has relatively

good access to all

allied health

services.

Patients with COPD

need a plan of care

with management

goals, including

self-management,

and the involvement

of multidisciplinary

team members.

Recruitment of the

workforce of

registered health

practitioners in the

field of exercise

physiology (and

others) has been

challenging.

The majority of people with COPD are managed in primary care.

Specialist referral is only needed for complex patients, young patients

(age < 40 years at onset), or where there is diagnostic uncertainty.


Key


Low

Medium

High

Disease burden

High

Medium

Low


Page 19 of 23

Table 7: COPD disease burden + availability of exercise physiology workforce by

LGA

Disease Burden Local Government Area Exercise Physiology Workforce

1 Flinders

Richmond

2

Aurukun

Cook Croydon Etheridge Hope Vale Kowanyama Lockhart River Mapoon Napranum Nth Peninsula Area Pormpuraaw Wujal Wujal Torres Strait Island

Torres

Weipa

3 Yarrabah

Cassowary Coast

4 Douglas

5 Tablelands

6

Charters Towers

Palm Island

Burdekin Hinchinbrook

7 Townsville

8 Cairns

9 Mackay

10 Isaac

11 Whitsunday


Australians in metropolitan areas receive more than double the level of service

provision from physiotherapists, podiatrists, occupational therapists and social

workers as those living outside of urban areas

– Australian Institute of Health and Welfare. Allied health workforce 2012

All Chronic Conditions

Page 20 of 23

Distribution of the occupational therapy workforce

Figure 8. All chronic conditions – disease level and disbtribution of occupational therapy workforce

Key Points

Croydon, whilst not

identified as being

of high risk for any

of the three socio-

demographic

indicators, ranks

second for all

chronic disease

PPHs.

Mossman reports

high-need service

for Ocuppational

Therapy particularly

in chronic pain.

Lockhart River,

Aurukun,

Kowanyama, and

Northern Peninsula

Area have at least

weekly access to

OT and social work

services.

Key


Low

Medium

High

Disease burden

High

Medium

Low

Technology has an important role to play in linking the visiting specialist

allied health providers with the local members of the care team.

Telehealth, videoconferencing and smart phones can enable the local

provider to share clinical images with the specialist allied health provider,

to consult with the allied health provider and to facilitate collaboration

between the patient and members of the patient’s care team



Page 21 of 23

Table 8: All chronic disease burden + availability of occupational therapy

workforce by LGA

Disease Burden Local Government Area Occupational Therapy Workforce

1 Flinders

Richmond

2

Etheridge


Croydon

Hope Vale

Pormpuraaw

Weipa

Wujal Wujal

Cook

Mapoon

Napranum

Nth Peninsula Area

Aurukun

Kowanyama

Lockhart River

Torres

3 Tablelands 4 Douglas

5 Yarrabah

Cassowary Coast

6 Mackay

7 Cairns

8 Whitsunday

9

Charters Towers

Palm Island

Hinchinbrook

Burdekin

10 Townsville

11 Isaac Notes: 1 Disease burden by SA3. Ranked 1 (High) – 11 (Low) 2 Service availability by LGA. Scored 1 (No available service) – 10 (Comprehensive available service)

Access to primary health care services is one of the key determinants of service

success and sustainability. Poor access, characterised as a barrier to seeking primary

health care at times of need, is the most important factor distinguishing rural from

urban health service use. – Australian Health Review 2015


Page 22 of 23

Distribution of the social worker workforce

Figure 9. All chronic conditions – disease level and distribution of social workers

Key Points

Yarrabah has a

significant shortfall

for social work.

For social work

services the

greatest need is at

Pormpuraaw,


and Wujal Wujal.

NQPHN does not

contract for the

provision of social

work services.

Naparanum and

Hope Vale have

social work services

visiting more

frequently than

weekly.

Yarrabah has a

marked shortfall for

social workers.

Key


Low

Medium

High

Disease burden

High

Medium

Low

Stakeholders identified a range of strengths and weaknesses of the

chronic care system in Northern Queensland, as well as opportunities for

NQPHN to commission services that can help overcome some of the

identified systems gaps.



Page 23 of 23

Table 9: All chronic disease burden + availability of social workers by LGA

Disease Burden Local Government Area Social Worker Workforce

1 Richmond

Flinders

2

Croydon

Etheridge

Pormpuraaw


Wujal Wujal

Mapoon

Aurukun

Lockhart River

Nth Peninsula Area

Hope Vale

Kowanyama

Napranum

Torres

Weipa

Cook 3 Tablelands 4 Douglas

5 Yarrabah

Cassowary Coast

6 Mackay

7 Cairns

8 Whitsunday

9

Palm Island

Burdekin

Charters Towers

Hinchinbrook

10 Townsville

11 Isaac Notes: 1 Disease burden by SA3. Ranked 1 (High) – 11 (Low) 2 Service availability by LGA. Scored 1 (No available service) – 10 (Comprehensive available service)

In an ideal world, there would be more formalised mechanisms where

we can co-commission to get more efficiencies and leverage off each

other to complement the service system. - Service Provider