“De-Feeting Wounds Regionally: Stepping into a Podiatry Led High

“De-Feeting Wounds Regionally:
Stepping into a Podiatry Led High
Risk Foot Clinic”
The implementation of an Advanced
Practice Role in Regional Allied Health
Let us introduce ourselves
•
Stacey Beacham – Project Lead and Assistant Manager of Primary Intervention at
Latrobe Community Health Service (Background in Podiatry)
•
Nicole Gawley – Advanced Practice Role Podiatrist, High Risk Foot Clinic Lead at
Latrobe Community Health Service. Also completed Post Graduate Certificate in
Diabetes Education
Acknowledgements
Primary
Petra Bovery- • Manager
Intervention, Latrobe
Spencer
Community Health Service
Susan Waller
• Senior Lecturer, Monash
University, School of Rural
Health
Shan Bergin
• Allied Health Education
Advisor & Senior Podiatrist,
Monash Health
Let us set the scene
The statistics
• 5378 people in the Latrobe Valley are
registered as living with Diabetes. Moe and
Morwell have the highest rates
• T2DM in Latrobe Valley has risen from 3.5%
to 5.1%. State average is 4.8%
• Diabetes Admission Rates Ratio in Latrobe
Valley is 1.6 compared with 1.0 for the rest
of Victoria
• 25% of people with diabetes will experience
foot ulcers
• Approx. 56% foot ulcers will become
infected
• 20% of these infected ulcers will end with a
some kind of lower extremity amputation
• 85% of amputations are preceded by a foot
ulcer
• (Diabetes Australia, AIHW, Wu et al 2007)
Issues Identified
Within LCHS
Outside of LCHS
Lack of availability for regular
appointments – Podiatry
appointments booked out up to 5
months in advance
No HRFC in the region – huge
financial toll travelling to Melbourne
Lack of funding for resources. Eg.
Testing equipment, dressings,
offloading footwear
Clients physically unable to travel
due to chronic and complex comorbidities
Lack of interprofessional
collaboration
Multiple metro and local
appointments – specialists,
podiatrist, diabetes ed, dietitian
No identified framework or client
pathway
Job security stress on client and
family
No relationships with external
agencies/stakeholders
All of the above contributes to the
emotional burden of living with a
chronic wound/amputation
So what happened next?
Petra Bovery-Spencer submitted an
application for the Allied Health
Workforce Grant Program to the
Department of Health (February 2015)
This submission was successful and
funding obtained to implement an
Advanced Practice Role in Allied Health
(March 2015)
This lead to the project of developing a
High Risk Foot Clinic at Latrobe
Community Health Service (LCHS), with
an Advanced Practice Podiatrist as the
clinic lead (April – December 2015)
Aims of Project
Consumer Focus
Optimisation of system
wide healthcare delivery
Career Progression
Optimisation of local
service delivery
Better patient access
Facilitate interdisciplinary
exchanges
Promote opportunities for
a range of roles
Improve productivity and
efficiency
Person centred care
Wider utilisation of
advanced practice roles
Provide extended scope of
practice opportunities
Minimise risk
Improve patient outcomes
Cross agency
collaboration & mentoring
Retain experienced staff in
the public system
Reduce patient visits
Promote consistent
discipline specific service
delivery models
Reduce acute hospital
admissions
Research to increase the
evidence base for
advanced practice
interventions
How did we do it?
Jan - April
• Engage
Project
Worker
• Identify team
• Review
literature
• Identify clients
• Meet Monash
HRFC
• Identify
stakeholders
• Develop
framework
May - June
• Site visits to
HRF clinics
• Develop roles
&
responsibilities
• Develop
resources
• Identify risks
• Establish client
pathway
• Marketing
• Disseminate
information
July - Sept
• Commence
clinic
• Operate on a
regular basis
• Multidisciplinary
team input
• Review clinic
standards working towards
best practice.
• Build client base
Oct – Dec
• Advanced
practitioner role
recognised
• Identify
additional skills
&
competencies
required
• Make
improvements
• Referrals in
both directions
• Secondary
consults
Jan - Now
• Submit ethics
application
• Ethics
application
approved
• Recruit
subjects &
collect data
• Fully
operational
clinic with
future
opportunities
for
expansion
identified
High Risk Foot Clinic Format
The Primary Team
• 3 Podiatrists (1 clinic lead/Advanced Practice Podiatrist)
• Dietitian
• Diabetes Educator
• Allied Health Assistant
• Counsellor
The Secondary Team
• GPs
• Wound Nurse
The Virtual Team
• Monash Health, Dandenong – High Risk Foot Clinic
Logistics
• Operates once a week at both Moe and Morwell sites
• Appointments generally 45 minutes
The Advanced Practice Role
Why do we need this role???
•
•
•
•
•
•
•
•
•
•
•
•
•
Screen referrals
Clinical support
Co-ordinate interdisciplinary exchanges
Arrange & lead case conferences
Provide guided care
Liaise with external agencies
Escalate clients
Client follow up
Manage consumables and stock
SWEP applications
Collect research data
Assess/minimise risk
Lead the clinic
Why does the project warrant research?
•
•
•
•
•
It is a first, in our region, for a stand-alone community health service
to operate a HRFC.
To evaluate client outcomes. Important to make sure we are actually
making a positive difference
To evaluate the effectiveness of the Advanced Practice Role and
team approach
To evaluate cost effectiveness and efficiency
To share our learnings with broader health and community services
Research background
Clinical Outcomes Data
Quality of Life Health
Questionnaire - EQ-5D-5L
Questionnaire for staff
involved in the HRFC
Clinical Outcome Data
Patients with a foot ulcer
Foot infections (type, swab)
Ulcer healing time
Patients with neuropathy
Referrals to specialists
Re-ulcerations after healing
Patients with vascular
disease
LCHS GP input
Patients discharged from
HRFC
Patients malnourished
Referrals to ED
Patients re-presenting to
HRFC
Patients with unstable
BGLs
Specialised footwear
Hospital admissions
Amputations (existing &
new)
Offloading devices issued
(boots, shoes, casting)
SWEP funding applications
Health Questionnaire
Staff Questionnaire
1. Do you think the introduction of the HRFC
service model is a positive for a. patients
and b. the organisation?
2. Does the HRFC function as a true
interprofessional model of care? If YES do you
think this is important? If NO why not?
3. What challenges have you experienced
during your involvement in the HRFC?
4. Do you find your role in the HRFC to be
professionally satisfying?
5. Do you believe your involvement in the
HRFC has increased your clinical knowledge
and skills around the management of the high
risk foot?
6. Do you feel the overall care provided to
clients in the HRFC has improved with the
introduction of this model?
7. Do you have any other feedback, positive or
negative regarding the introduction of the
HRFC?
What did we find so far?
Better
diabetes
control
Less
DNAs
Less
financial
stress
Better self
management
Less
time
off
work
Less
travel
Better
access
to
services
Improved
wellbeing
Less
appointments
Wounds
are
healing
faster
Client
does not
need to
re-tell
their
story
Less
waiting
time
Better
rapport
with
clinicians
More client
centred
care
What did we find so far?
Offers the
opportunity
to specialise
Staff feel a
valued
member of
the team
Extended
scope of
practice
opportunities
Great
opportunities
for career
progression
Able to
recruit
quality
staff
Improved
job
satisfaction
Better
relationships
between
agencies &
stakeholders
Improved
team work
& team
bonding
Interprofessional
learnings
Challenges
No expert in the
field at LCHS
Timetabling of a
multi-disciplinary
team
How to
financially
sustain the clinic
Client reluctance
in attending a
multi-disciplinary
clinic
Finding relevant
training for up
skilling
Establishing
linkages with
local specialists
Our key learnings
Leadership
• Clear clinical leadership is essential
• Capabilities consistent with the framework
• Background and strong interest in the field (does not need to be an
expert)
Team approach
• Interprofessional collaboration leads to the best results
• Improved job satisfaction = happier staff
• Client centred = improved patient outcomes
Strong Relationships
• Network, network, network
• Feedback regularly to referrers and external agencies
• Don’t be afraid to ask when unsure