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HEALTH MATTERS Victorian Healthcare Association ISSUE 1 [ JULY 2015 ] vha.org.au Study challenges stroke treatment Search for pre-eclampsia cure How childhood trauma impacts health PHNs, politics and patience

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Page 1: Health matters july 2015

HEALTH MATTERSVictorian Healthcare Association

ISSUE 1 [ JULY 2015 ] vha.org.au

Study challenges stroke treatment

Search for pre-eclampsia cure

How childhood trauma impacts health

PHNs, politics and patience

Page 2: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION2

8 Community health left to treat fallout from trauma

6 When should we mobilisepatients after stroke?

Health Matters content is protected under the Commonwealth Copyright Act 1968 and may not be reproduced in part or in whole without written consent from the VHA. We welcome editorial submissions that are relevant to the public healthcare sector. Please email material and images with a minimum 300dpi to [email protected].

The Victorian Healthcare Association (VHA) is an independent, not-for-profit peak body working to improve population health outcomes through the advancement of health service delivery across Victoria. Our members include public hospitals, rural and regional health services, aged care facilities, community health services and Medicare Locals.

THIS ISSUE

For editorial content please contact:SARA BYERSMedia and Communications Manager

The Victorian Healthcare AssociationLevel 6, 136 Exhibition StreetMelbourne, Victoria 3000 Australia

Telephone: +61 3 9094 7777Email: [email protected]

3 Our new Chief Executive Officer

4 Coordinating healthcare: PHNs, politics and patience

6 When should we mobilise patients after stroke?

8 Community health left to treat fallout from trauma

9 Trauma and homeless initiative at Inner South CHS

10 Police-clinician response eases hospital pressure

11 Severe behaviour response teams

12 How will hospitals be funded in the future?

13 Mercy research aims to cure pre-eclampsia

14 Health-Justice Partnerships

16 Canadian study tour of community health centres

17 Merri CHS gets in touch with its inner HIPPY

Cover image: Victorian Health Sector.

13 Mercy research aims to cure pre-eclampsia

Page 3: Health matters july 2015

3ISSUE 1 [JULY 2015] VHA.ORG.AU

Chair of the VHA

Board Gary Thomas

is confident Tom will

build on his previous

work as Acting CEO.

“Tom’s experience,

enthusiasm and the

strong rapport he has already developed with the

health sector put him in good stead to drive the VHA’s

agenda in ensuring Victoria’s health services are well

supported into the future.”

“It is crucial that the VHA takes a prominent role in

standing up for the sector at a time when the population

is growing, ageing and the rates of obesity and chronic

diseases are rising.”

Mr Symondson is looking forward to working with VHA

members, governments and public health organisations

to build on Victoria’s world-class health system and ensure

it continues to be innovative, effective and sustainable.

“My vision for the VHA is to ensure we do not become

complacent, that we rise to the challenge of remaining

relevant to the membership and supporting them to

deliver health services to their local communities,”

Mr Symondson said.

“I also believe the VHA has a strong role in fostering

innovation at the system level to meet the growing

demand for healthcare in our community.

“This is an organisation and a sector that I am extremely

passionate about and I’m committed to the VHA

projecting a united voice to government, stakeholders

and the public, championing both the successes and

the needs of our health and community health services.”

The VHA is delighted to confirm the appointment of Tom Symondson as our new CEO.

Our new Chief Executive Officer

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Page 4: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION4

Yet, as many of us in the sector know, this is often

not the case.

In fact, a lack of co-ordination is at the root of so many of the challenges facing health providers every day, from the lack of integrated IT systems between providers to a lack of comprehensive population health-based planning for our communities.

The sector has grappled with these issues for as long

as most people can remember - often with frustration,

sometimes tears.

And aside from the economic inefficiencies and impact

on the stress levels of staff, it is ultimately health

consumers who are affected.

Successive governments have periodically sought

to overcome these challenges, most recently with

the establishment of 31 new Primary Healthcare

Networks or PHNs.

They are the latest in a succession of organisations

tasked with co-ordination of our complex primary

care system and integration with the acute sector.

Back in 1992, the Keating Government established

Divisions of General Practice to improve access to care,

develop approaches to prevention, early intervention

and chronic disease management, support integration

and increase the focus on population health.

Brian Howe, then Minister for Health, said of these

Divisions: “Our reform strategy will end the professional

isolation of general practitioners and help them to lift

the standard of care for all their patients.”

“[It] will provide a regional framework to improve

general practice in five key areas: better after hours and

home visits; a better general practice locum service;

rebuilding the links between general practice and

hospitals; involving general practitioners in community

health advancement programs; and developing quality

assurance processes for general practice.”

Much of this sounds very familiar today.

Fast forward 20 years to the Rudd/Gillard Government’s

staged introduction of 61 Medicare Locals. They were

tasked with shifting the focus away from GPs and

towards engaging and connecting the broader primary

care sector, and linking it more effectively with hospitals.

In opposition, the Coalition criticised Medicare Locals

as a bureaucracy that was being funded at the expense

of frontline services.

A few short years later, the Coaltion won government

and commissioned a review into Medicare Locals led

by Professor John Horvath AO, a former Chief Medical

Officer under Prime Minister John Howard.

The Abbot Government released the Horvarth review’s

findings on the eve of the 2014 Commonwealth Budget.

Prof Horvarth remarked that Medicare Locals lacked

‘a clear purpose’ and had delivered ‘inconsistent

outcomes’ which resulted in many patients continuing

to experience fragmented healthcare.

If we accept that practitioners and health services do not always talk to each other, or coordinate the delivery of care, then it follows that getting this to occur – establishing trust, shifting entrenched behaviours, cultivating the right conditions and pulling the right levers – will take significant time and patience. It’s a bit like herding cats.

In this context, Prof Horvath’s report reads like a pretty

damning indictment of organisations that were no more

than three years old.

He recommended the establishment of new ‘Primary

Health Organisations’ with the aim of improving health

outcomes by integrating and coordinating health services.

And so here we are, 12 months later, with six PHNs about

to commence operations in Victoria. Minister for Health

Sussan Ley has said that PHNs will be ‘outcome focussed’

on improving frontline services and ensuring better

integration between the primary and acute care services.

It would seem reasonable to assume that co-ordination and integration are accepted, even compulsory, features of our health system. The general public may take for granted the idea that health services, GPs, dentists and allied health professionals all talk to each other and share a single record about a patient.

Coordinating healthcare: PHNs, politics and patience

Page 5: Health matters july 2015

5ISSUE 1 [JULY 2015] VHA.ORG.AU

Coordinating healthcare: PHNs, politics and patience

The historical backdrop against which the new PHNs

have been established, coupled with the size of their

catchments, will no doubt pose some hurdles going

forward. But it is important to view PHNs as a new

opportunity to build on the good work of the past.

Rather than dwelling on the challenges associated with maintaining local connections and understanding local health issues, why not focus on the potential for enabling true regional planning that scale brings?

Expectations of all stakeholders, from Minister Ley

down, are undoubtedly high. The challenge for

PHNs will be to manage those expectations so they

don’t share the fate of their predecessors. They also

have an opportunity to deliver real change – to this

end, speed of execution will be key.

For the VHA’s part, we will be working with PHNs,

hospitals, community health services and others to

signal to governments (and oppositions) that PHNs

should be treated as core components of our

healthcare system, not merely add-ons. And the

best way to signal this is to practise it.

Far from making our sector more complex, if PHNs

roll out as we hope, they should help make the health

system simpler to navigate for consumers and providers.

Against this key objective, we all have skin in the game.

Because in another ten years– or even in three –

is it really in the community’s interest to see them

consigned to the wasteland, only for us to return

to the drawing board yet again?

Tom Symondson

Chief Executive Officer

Victorian Healthcare Association

Victoria’s new Primary Health Networks

WESTERN VICTORIA

MURRAY

GIPPSLAND

NORTH WESTERN MELBOURNE

EASTERN MELBOURNE

SOUTH EASTERN MELBOUNRE

Page 6: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION6

However, embedding evidence-based practice in

clinical settings is complex – cultural change is required,

clinical practice guidelines require review, and a general

shift in clinician approach must occur.

Translation of research into practice is not a new issue

for health services or policy makers, where evidence-

based practice must be balanced against pragmatism

and cost.

According to the Australian National Health and

Medical Research Council (NHMRC), systematic reviews

of randomised controlled trials (RCTs) are the most

robust form of evidence, followed closely by properly

designed RCTs.

However, designing an RCT that will obtain ethics

approval in a clinical setting is no easy task. In April

2015, Professor Julie Bernhardt and her research team

published the results of a landmark RCT in The Lancet.

A Very Early Rehabilitation Trial (AVERT) was a single-

blind, multicentre, international randomised controlled

trial examining the efficacy and safety of very early

mobilisation after the onset of stroke.

Acute stroke units are designed to provide specialist

care for stroke patients, and the use of early

mobilisation has long been believed to lead to improved

mobility, aligned with the theory of neuroplasticity.

Current clinical practice guidelines for acute stroke

management are non-prescriptive and recommend

‘early mobilisation’ within 24 hours; however there

is no clear definition of ‘early mobilisation’ or evidence

to support this.

When should we mobilisepatients after stroke? Healthcare delivery must be underpinned by evidence to ensure patient outcomes are optimised, safety is considered, and that services are delivered in an efficient and effective manner.

Acknowledging this, AVERT used a specified

mobilisation dose, which was guided by a detailed

intervention protocol.

The study recruited 2104 eligible patients from

56 stroke units in the UK, Malaysia, Singapore,

New Zealand and metropolitan Melbourne between

July 2006 and October 2014.

The National Stroke Research Institute (part of the Florey

Neuroscience Institute of Neuroscience and Mental

Health) coordinated the involvement of the Austin

Hospital, Alfred Hospital, Royal Melbourne Hospital,

St Vincent’s Hospital and Western Health.

With a sample size more than 10 times that of previous

comparable trials, AVERT was the world’s first large

rehabilitation trial led by physiotherapy and nursing staff

with patients recruited within 24 hours of stroke onset.

Within this ground-breaking framework, AVERT

produced unprecedented results by demonstrating

that very early mobilisation led to reduced patient

outcomes three months after stroke – in contrast with

previous work by the same research group and other

smaller trials.

The AVERT group that was mobilised 4.8 hours earlier

than the control group, and with 21 more minutes a day

of mobilisation, had worse outcomes at three months’

disability. There were no differences in mortality or

length of stay between groups.

Director of Western Health’s Stroke Unit & Neuroscience

Research Unit, Professor Tissa Wijeratne, led the

Western Health research group with Stroke Nurse

Practitioner Elizabeth Mackey and contributions from

other stroke nurses, allied health researchers and

neurology registrars.

Page 7: Health matters july 2015

7ISSUE 1 [JULY 2015] VHA.ORG.AU

“Before AVERT, evidence for early mobilisation after

stroke came from three small studies including 159

patients,” Prof Wijeratne said.

“Our research group will continue to collaborate with

La Trobe University, University of Melbourne, Monash

University and the Florey Institute to find answers

to these questions in the coming months and years.”

Professor Wijeratne said there were still unanswered

questions, such as:

• when should we start rehabilitation after acute

stroke?

• what should acute stroke rehabilitation consist of?

• why do some patients respond better to a more

conservative approach while others do better

with more therapy?

• does an enriched rehab environment offer better

outcome after stroke?

• would improved understanding of molecular

mechanisms induced by early physical activity

on stroke affected brain tissue hold some of

the secrets behind early rehabilitation?

The National Stroke Foundation will be reviewing this

ground-breaking research when its Clinical Guidelines

for Stroke Management are updated.

This article was written by VHA Policy Advisor Weif Yee.

The Key toBreakthroughs inPatient Care

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Page 8: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION8

Adverse childhood experiences occur in all types

of communities, but are more prevalent low income

and diverse ethnic and racial communities, which

means community health centres in the United States

are playing a disproportionate role in addressing the

health consequences of childhood trauma across the

life course.

Research by the Washington State University (WSU)

Area Health Education Center has found that between

40 and 45 per cent of children in low income families

have multiple exposures to such experiences.

WSU and the Northwest Regional Primary Care

Association (NRPCA) have jointly launched the

Trauma-Informed Primary Care Initiative.

“While adverse childhood experiences help us

understand the staggering nature of the risks that

are dealt with in primary care, understanding this risk

does not describe what can be done to address the

problem.” says the Manager of NRPCA’s Community

Health Improvement Program, Seth Doyle.

“As a result, the core policy and practice demand

is to develop effective models for how to provide

care, given our knowledge of the impact of adverse

childhood experiences.”

The Trauma-Informed Primary Care Initiative has

established that:

• adverse childhood experiences are now the main

social determinant of ill-health in the United States,

where between 25 and 30 per cent of children

grow up in families and communities that put their

lifelong mental, social and physical health at risk

• in resource-poor communities where CHCs

operate, the impact of trauma is even more

pervasive, with most patients at risk

• complex trauma treatment principles, which

recognise and respond to trauma, are adaptable

to primary care settings

• there is a movement towards integrating trauma

treatment principles into primary care practice

to address both physical and behavioural health

USA community health left to treat fallout from trauma Childhood trauma represents a public health crisis affecting the health and life path of approximately one in three Americans.

The impact adverse childhood experiences have on

brain development and the resulting coping behaviours,

which become barriers to improving health outcomes,

are evidenced in more than 600 peer-reviewed studies.

The Adverse Childhood Experiences (ACE) study

is one of the largest investigations ever conducted

into childhood maltreatment and later-life health

and wellbeing, suggesting that certain experiences

are major risk factors for the leading causes of illness,

death and poor quality of life in the US.

Harvard University research on the biology of stress

now shows that healthy development can be derailed

by excessive or prolonged stress responses in the

body (especially the brain), with damaging effects

on learning, behavior, and health across the lifespan.

Further reading:

Eastern Washington Area Health Education Center ext100.wsu.edu/ahec

Centers for Disease Control and Prevention dc.gov/violenceprevention/acestudy

Harvard University Center of the Developing Child developingchild.harvard.edu

Page 9: Health matters july 2015

9ISSUE 1 [JULY 2015] VHA.ORG.AU

Five years ago, ISCHS interviewed 985 of its homeless

clients and found a significant number of them had

experienced traumatic events before becoming

homeless.

ISCHS responded by joining forces with Sacred Heart

Mission, Mind Australia, and VincentCare Victoria to

commission further research by the Australian Centre

for Posttraumatic Mental Health.

“It looked like our client group had suffered a lot of

trauma, so we were very interested in finding out the

connection between that and their need for extensive

services,” says ISCHS General Manager, Primary and

Mental Health Alan Murnane.

“We wanted to understand where the trauma sat in

people’s backgrounds and how we might go about

working with them.

“We also wanted to demonstrate the link, which we

were aware of although we didn’t have any evidence,

that most people using our homeless services had at

some stage faced trauma in their life.”

Trauma and homelessness initiative at Inner South CHSA study conducted through Inner South Community Health Service (ISCHS) has found a cyclical relationship between trauma, long-term homelessness, mental health difficulties and social disadvantage.

The Trauma and Homelessness Initiative involved a

literature review and qualitative interviews with 20

service users, all of whom reported experiencing at

least one traumatic event in their lifetime. Staff focus

groups were also conducted with 42 case workers.

Finally, a quantitative study of 115 homelessness

service users found that 98 per cent had experienced

type I (single incident) trauma and 60 per cent had

experienced type II (chronic childhood) trauma

There were very high levels of exposure to interpersonal

violence (including sexual and physical assault),

natural disasters, and life-threatening accidents,

and most participants reported exposure to multiple

traumatic events.

“Most of them had experienced trauma before they

were homeless,” Mr Murnane says. “But the trauma

they experienced after becoming homeless was much

greater because, in fact, being homeless is a trauma

in itself.”

RESEARCH FINDINGS

• Traumatic events are often a precursor to

becoming homeless – many people left their

home to avoid ongoing trauma such as assault,

child abuse and interpersonal violence.

• Being homeless is a risk for experiencing further

trauma – the frequency of trauma exposure

escalated when people lost their secure

accommodation.

• Trauma, especially that caused by a primary

caregiver, impacts on a person’s sense of safety

and connection with other people, and on their

ability to maintain social relationships.

• Trauma drives mental health problems – this client

group had increased rates of psychiatric disorders

and other adverse mental health experiences.

DEFINING TRAUMA

• Type I trauma events occur at a particular time

and place and are usually shortlived, such

as natural disasters, serious motor vehicle

accidents, sudden death of a parent, or a single

incident sexual assault.

• Type II trauma events are chronic, begin in early

childhood, and occur within the child’s primary

care-giving system or social environment. They

are usually repetitive or prolonged; may involve

direct harm or neglect by caregivers; and are

associated with complex and long-term mental

and social difficulties.

Further reading:

ischs.org.au/resources/research-and-evaluation/trauma-and-homelessness-initiative-thi/#&panel1-1

Page 10: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION10

Police, Ambulance and Clinician Early Response (PACER) is being rolled out across Victoria following successful programs in the municipalities of Bayside, Kingston and Glen Eira and at Eastern Health, Alfred Health, Northern Health and Peninsula Health.

Southern Health and Moorabbin Police started Victoria’s first PACER program in 2007, after studying similar models in the United States.

Evaluation of the program found that people suffering a behavioural disturbance were less likely to present at an emergency department (ED) and that police units were released to other duties more quickly.

State government funding was announced last year for PACER to be run by each of Victoria’s 21 Area Mental Health Services.

North Western Mental Health nurse Steve Brown says there has been a decrease in mental health presentations at Northern Hospital, which has one of Melbourne’s busiest EDs.

“People living with mental illness, who are in crisis, can be attended by trained police and clinicians in their home,” Mr Brown says. “This eases the impact on hospital emergency departments and significantly reduces the individual’s distress and anxiety.”

Since Peninsula Health introduced PACER in April 2014, the number of mental health patients treated at Frankston Hospital’s ED has dropped by 86 per cent. The program has recently been extended to Rosebud, assisting 57 clients in its first three months.

A joint response from police and mental health teams to people experiencing behavioural disturbance in the community is reducing the number of mental health presentations at Victorian hospitals.

“By placing a mental health clinician in the peak of the situation, nine times out of 10 we are able to defuse the situation and treat and support clients in their own home,” mental health clinician Sarah Coffey says.

“By providing an on-the-spot response we are often able to avoid the person being transferred to the Emergency Department by police or ambulance.”

She and colleague Dwight Smith are clinicians in the Peninsula Health PACER program, which runs seven days a week from Frankston Police Station. They also provide a secondary response service to Frankston, the Mornington Peninsula and parts of neighbouring Casey.

In addition to freeing up police and emergency department resources, Ms Coffey says it has also had a positive impact on patients and their families.

“Often, in the sort of the situations we attend, the ¬patients will feel they are in trouble and that they have done something wrong ¬because the police are there.

“By bringing in someone in a therapeutic role rather than an authoritative role, we are able to provide support for patients and families.”

“We work with people who have existing mental illness and those having acute one-off episodes. It is often a matter of de-escalating the situation, treating them and referring them into the most appropriate care.

“It is better for everybody if we are able to treat people in a familiar environment where they feel safe rather than taking them into hospital unnecessarily.”

Peninsula Health mental health clinician Sarah Coffey (left) and a local police officer with a client.

Police-clinician responseeases hospital pressure

Page 11: Health matters july 2015

11ISSUE 1 [JULY 2015] VHA.ORG.AU

Run by Hesse Rural Health, Hesse Lodge has 24 high and low care aged care beds. Rural surrounds make it familiar and comforting for residents, most of whom are local people living with dementia.

CEO Peter Birkett hopes that a new federal government program of Severe Behaviour Response Teams (SBRT) will not diminish the safe and welcoming environment at Hesse Lodge.

The SBRT program will replace the dementia supplement previously paid to service providers and will be funded through the same allocation of $54.5 million over four years.

Multidisciplinary response teams will provide expert advice to residential aged care facilities needing assistance to care for residents with severe behavioural and psychological symptoms of dementia. Initially, they will work with existing Dementia Behaviour Management Advisory Services (DBMAS) but will become fully integrated with DBMAS from 2016-17.

“A funded replacement to the former supplement is very much welcomed, but we have concerns about implementation,” Mr Birkett says.

“Here at Hesse we are recognised for the positive effect our environmental design has and for our staff. As a rural facility, we worry about how city-centric this approach will be to what is a large problem in many rural and regional areas.

“We support the investment, but the review of dementia

responses also needs to include environmental design

and ongoing staffing approaches.

“Roaming teams of experts may work in the first

instance, but building capacity through a whole-of-

workforce approach and much-needed training for staff

can’t be forgotten. Ideally, we’d like to see funding for

appropriate internal expertise to work with residents

on an ongoing basis.”

The potential for chemical and physical restraints to

be used concerns Mr Birkett, as Hesse prefers to use

restraint-free options for distressed residents.

A comprehensive patient assessment, care planning

and consent process is followed before restraints are

used, in order to meet Commonwealth guidelines and

mandated reporting requirements.

“For people living with dementia, having familiar rather

than transient staff is important. We’d like to see our

current staff trained to better manage behaviours,”

he says.

“Essentially, we don’t want our residents waiting

for necessary services due to the location of SBRT,

or to have them further upset by unfamiliar faces, who

may be more predisposed to administering physical

or chemical restraints as a response to a resident’s

further distress at a change in routine.”

A recent unscheduled evaluation of Hesse Lodge by

the Residential Aged Care Standards Agency reported

a “relaxed atmosphere in the dementia environment

with a focus on activities and meaningful engagement”.

Mr Birkett says: “Hesse is a place for the people of

this community to come when they need help to cope

with living with dementia. We want the environment

to be comfortable, safe and welcoming. We want our

residents’ families to feel that when they visit too. We’ve

done everything we can to run Hesse as an example

of best practice, and we want to make sure SBRTs add

to that not diminish it.”

Severe behaviour response teamsHesse Lodge Nursing Home is slightly different to the average residential home, both in design and attitude. There is an abundance of natural light; staff are present but unobtrusive; doors and windows are open; and an old ute sits out the back in a large garden, which has a workshop of tools for residents to tinker with.

Hesse Lodge Nursing Home

Page 12: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION12

How will hospitals befunded in the future?

Speaking at a VHA forum after the Commonwealth Budget was delivered in May, Mr Breadon said that public hospitals needed binding or legislated agreements to ensure their future funding arrangements.

“I’d like to see medium-term agreements which are certain, enforceable and linked to activity. I’d also like to see the opportunity to get much more transparency about performance at a state and provider level,” he said.

“Within health, hospital funding has clearly been the fastest-growing component but current funding for Australia’s public hospital system is unsustainable. This is a big unanswered question: how are we going to fund public hospitals in the future?”

To answer this question, Mr Breadon speculated on the following scenarios:

• increasing state tax, which may become

a necessity

• increasing commonwealth funding, however

reinstating previous levels of commonwealth

funding is unlikely

• a major shift in roles, responsibilities and/or tax

revenue between the Commonwealth and the

states, which is also unlikely

• removing avoidable hospital costs, as identified in

the Grattan Institute report Controlling Costly Care

which states: “The gulf between treatments in high

and low-cost hospitals in Australia is vast, with no

good reason for such variation. This money is not

being used to provide better care – it is simply

being spent inefficiently and could be used for

much better ends”.

Grattan estimates that $1 billion in avoidable hospital

costs could be saved nationally if state governments:

• paid hospitals for treatments on the basis of an average

price once all avoidable costs have been removed

• made data available to hospitals so they can

compare themselves to their peers and see where

they can cut costs

• held hospital boards to account when they fail

to control costs.

“There is huge variation, which suggests that there

is room for greater efficiency in the system,” Mr Breadon

explained. “In future, if the Commonwealth is going to

ask ‘how do we calculate a more efficient price?’.

“The Commonwealth may also look for greater

accountability and transparency in the system, for

example, evidence for future demand growth may

need to demonstrate that the demand is legitimate

and the services are high-value.”

Although the Commonwealth has announced reviews

into primary care, the Medical Benefits Scheme and

the Pharmaceutical Benefits Scheme, Mr Breadon said

it was disappointing that the May budget didn’t address

primary care:

“There is no big picture for primary health in this year’s

Commonwealth budget. They haven’t talked about

Primary Health Networks or given any more detail on

their funding. They haven’t talked about preventative

health or chronic disease management.”

He also said there was “no clear vision” for what the

Medical Research Future Fund should focus on: “Let’s

have some long-term, high-quality, well-funded trials

of some preventative measures and healthcare delivery

models – things that we can’t get the IP for from other

countries, things that are more about system design

and service delivery. I’d love to see us having a crack

at solving some of these riddles.”

Certainty must be a key feature of any future health funding agreement between the Commonwealth and the states, according to the Grattan Institute’s Health Fellow Peter Breadon.

Grattan Institute’s Health Fellow Peter Breadon

Page 13: Health matters july 2015

13ISSUE 1 [JULY 2015] VHA.ORG.AU

Dr Brownfoot, 31, completed three years of clinical

training at the Royal Women’s Hospital before moving

to the Mercy Hospital for Women to complete her PhD

under the supervision of Professor Stephen Ton and

Dr Tu’uhevaha Kaitu’u-Lino.

Pre-eclampsia is one of the most common complications

of pregnancy, affecting between five and eight per

cent of pregnant women. It occurs when the placenta

releases toxins into the mother’s blood stream, causing

widespread damage to her blood vessels and often

leading to multisystem organ damage.

There is no treatment for pre-eclampsia – the only

way of stopping it is to deliver the baby, which carries

minimal risk at the end of a pregnancy. But at preterm,

the disease leads to high rates of infant morbidity and

mortality.

Dr Brownfoot is researching the safety and efficacy of

treating pre-eclampsia with Pravastatin – a cardiovascular

medication that is widely used to reduce high cholesterol.

“Animal models suggest that it may be able to stabilise

pre-eclampsia and we’ve further investigated its effects

on human tissues with very encouraging results. Our

main goal is to find a medical therapeutic that might

allow mothers to extend their pregnancies until it’s safe

to deliver their babies,” Dr Brownfoot says.

“I’ve always had a real interest in research, inspired by

my clinical work. Even now, very little is known about

some of the most common obstetric complications,

including pre-eclampsia, and there are very few medical

treatments for them. Research on these conditions

can have a big impact on improving outcomes for

our women and babies.”

Other research has focused on preventing pre-

eclampsia with vitamins C and E, and aspirin. While

aspirin has been shown to reduce the incidence,

vitamins were found to be ineffective.

“There are ongoing studies on heparins and, more

recently, on pravastatin as a possible medical

therapeutic,” she says.

Mercy Hospital research aims to cure pre-eclampsia In her final year of training to qualify as an obstetrician-gynaecologist, Dr Fiona Brownfoot decided to become a clinician-scientist and find a cure for pre-eclampsia in preterm pregnant women.

“Our lab-based studies and our clinical trial on

pravastatin are looking really promising. We’ve recruited

four women so far. They were really excited about the

potential and the hope that we may be able to come

up with a treatment.”

“Together we hope we’ll be able to make a difference

for them, for other women and for their children. The

outcomes could give women a much brighter future

in terms of their own health and that of their babies.”

The study needs to recruit eight more women from

23 weeks gestation who have pre-eclampsia.

“If we are able to treat the pre-eclampsia in these

preterm women then we might be able to get better

perinatal outcomes. Every day really counts at this early

stage of gestation in pregnancy.”

Similar trials are underway in the UK and US but both

these studies are still recruiting and have not released

any results yet.

Dr Brownfoot won the Laxmi Baxi award for outstanding

research at the Society of Reproductive Investigation in

San Francisco in April 2015, and the ISSHP president’s

award at the International Conference for the Study of

Hypertension in Pregnancy in New Orleans in 2014.

She has amassed 11 journal articles, attracted $180,000

in research funding during her PhD and won a number

of New Investigator Awards.

Dr Fiona Brownfoot

Page 14: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION14

Legal services that are integrated into health settings

are an important part of this multi-disciplinary approach,

because legal needs are considered one of the social

determinants of health.

This was recognised by the Legal-Australia Wide

Survey (the LAW Survey) conducted in 2012, which

found that legal problems often have negative impacts

on many life circumstances including health, financial

and social circumstances.1

Integrating legal services into healthcare settings

allows clinicians to provide wrap-around care

to their patients, and builds on existing research

into advice-seeking behaviour.

Known in Australia as Health-Justice Partnerships,

these integrated services are based on Medical-Legal

Partnerships, which currently exist at 276 healthcare

institutions across the United States (US).2 This

model is gaining momentum in Australia, with several

partnerships now in place at hospitals and community

health centres.

Inner Melbourne Community Legal (IMCL) has

established partnerships with the Royal Women’s

Hospital (the Women’s), the Royal Children’s Hospital

and Inner West Area Mental Health Services.

At the Women’s, IMCL has provided almost 300

instances of free, on-site legal advice on birth

certificates, family law and child support, child

contact and divorce, family violence and fines.

On-site legal services provide a direct referral pathway

for clinicians whose patients raise legal questions.

It is hoped that by breaking down the silos between

health, social and legal professionals, Health Justice

Partnerships will bring about greater access to justice

as well as better health outcomes for individuals

in our community.

Health-Justice Partnerships There is growing recognition in Victoria of the importance of providing holistic, multi-disciplinary care to the most vulnerable and disenfranchised people in our society, to ensure they do not fall through the safety net.

THE EVIDENCE

• The 2012 LAW Survey found that legal problems

caused physical ill-health in 19 per cent of cases;

stress-related illness in 20 per cent of cases,

and that disadvantaged people “are particularly

vulnerable to legal problems, including substantial

and multiple legal problems”. The survey found

that people seek legal assistance from non-legal

advisers in approximately 69.7 per cent of cases

and they seek to resolve their legal issue by

consulting health or welfare advisers in 27.2

per cent of cases.3

• LegalHealth surveyed 51 cancer patients and found

that legal assistance led to a significant reduction

in stress for 83 per cent of respondents and an

improvement in the financial situation of 51 per

cent of respondents.4

• A US study at St Luke’s Roosevelt Hospital found

that asthma patients who received legal interventions

had “significant improvements in the severity of their

condition, and fewer emergency room visits, than

patients who did not receive legal assistance”.5

• A Robert Wood Johnson Foundation survey

of 1000 physicians found that 85 per cent believed

“unmet social needs are directly leading to worse

health” and 80 per cent were “not confident in their

capacity to address their patients’ social needs”.6

This article was written by IMCL Senior Project Manager and Lawyer, Linda Gyorki, who will host a workshop at the VHA Rural and Regional Forum on Thursday 6 August. Bookings: vha.org.au/events

Linda is a Churchill Fellow, whose research into the practical and ethical barriers of integrating legal assistance into a healthcare setting is available at: churchilltrust.com.au/fellows/detail/3816/Linda+Gyorki

Footnotes:

1 Christine Coumarelos et al “Legal Australia-Wide Survey: Legal need in Australia” (Report, Law and Justice Foundation of New South Wales, August 2012) xvi-xvii.

2 National Center for Medical-Legal Partnership http://medical-legalpartnership.org

3 Coumarelos et al, above n1, 135.

4 Wendy Parmet, Lauren Smith & Meredith Benedict, “Social Determinants, Health Disparities and the Role of Law” in Elizabeth Tobin Tyler et al (eds), Poverty, Health and Law: Readings and Cases for Medical-Legal Partnership (Carolina Academic Press, 2011), 26.

5 R Retkin et al., “Medical-Legal Partnerships: A Key Strategy for Mitigating the Negative Health Impacts of the Recession”, Health Law, 22 (2009): 31 in Parmet, Smith & Benedict above n.17, 26.

6 Daniel Atkins, Shannon Mace Heller, Elena DeBartolo and Megan Sandel, “Medical-Legal Partnership and Healthy Start: Integrating Civil Legal Aid Services into Public Health Advocacy” (2014) 35(1) The Journal of Legal Medicine 195, 199.

Page 15: Health matters july 2015

15ISSUE 1 [JULY 2015] VHA.ORG.AURK Ad Health Matters 0515_final.indd 1 20/05/2015 3:54 pm

CASE STUDY

The Women’s referred Kate* to a lawyer at IMCL.

She was in a violent relationship and had been

assaulted by her partner while pregnant. She

was physically assaulted, falsely imprisoned,

and threats to kill had been made to Kate

and her unborn child. She reported the incident

to police, who applied for an intervention order

on Kate’s behalf.

Kate stayed away from her partner for a time,

but after he made assurances that it would not

happen again, she returned to him because she

was pregnant and felt there was nowhere else to go.

Kate applied for a variation to the intervention order

to allow her partner to see and contact her. However,

several days later, her partner was again violent and

abusive, this time in front of her friend’s children,

which prompted Kate to take action.

When IMCL first met Kate, she had recently given

birth. IMCL helped her to withdraw her variation

application, so that a full intervention order remained

in place. IMCL also advised Kate on how to add her

child to the intervention order.

The Department of Human Services had contacted

Kate over concerns for her child’s safety. IMCL advised

Kate on how to work with the department to ensure

they both remained safe and together. The department

subsequently closed its file, satisfied that Kate was

taking all available measures to protect her child.

IMCL also helped Kate apply to the Victims of Crime

Assistance Tribunal for financial assistance to help

her recover from the crime. Within four months, the

Tribunal awarded Kate a lump sum of special financial

assistance, approval for counselling, installation of a

security system, remedial massage and self-defence

classes. In total, Kate received almost $9,500 in

financial assistance.

* name has been changed to protect identity

Page 16: Health matters july 2015

THE VICTORIAN HEALTHCARE ASSOCIATION16

Lynne Raskin is CEO of South Riverdale Community

Health Centre (SRCHC), providing primary care and health

promotion programs in Toronto, one of Canada’s most

populated and linguistically and culturally diverse cities.

She joined US and Canadian delegates on a whirlwind

10-day study tour of Victorian community health

services in April.

Hosted by the Victorian Healthcare Association

and Community Health Australia, the tour facilitated

information sharing on local approaches to chronic

disease management, community governance

and engagement, and the integration of primary

healthcare with social services.

SRCHC offers several dedicated Chinese language

services, including a cancer support group, breast feeding

consultants as well as nutrition and diabetes counselling.

“We are currently working on nurse practitioner-led

clinics to integrate the services our communities need,

in their first language,” Ms Raskin says.

“A nurse practitioner offers a different approach to

a doctor – they explain things in layman’s terms and

provide holistic care and social support with less

expense for the patient and for our organisation.

“We at SRCHC think that health must cross several

boundaries; we aren’t just concerned with acute illness,

but also with social support, health prevention programs

and holistic care that suits each individual. Inclusive

and accessible healthcare is our mission.”

The study tour included a visit to Leichhardt Women’s

Community Health Centre and its satellite site in

Lakemba, western Sydney, where Ms Raskin and

her fellow delegates were able to compare their

experiences of working with culturally and linguistically

diverse communities.

“It was fantastic to meet people who are interested

in the same topics and providing the same style

Canadian study tour of community health centres In the space of 10 days, Lynne Raskin caught six flights, visited eight community health centres, presented at a national conference, met with the Victorian Department of Health and Human Services, participated in a primary and community health roundtable, explored two cities and finally learnt how to make a smoothie in a blender powered by a bicycle she rode herself.

of care, conscious of social determinants and respectful

of individual needs. The services and outcomes at

Leichhardt Women’s provided insights we can take home.”

In Victoria, the tour included visits to Ballarat Community

Health Centre, Merri Community Health Services,

Aboriginal Medical Services Redfern, Inner South

Community Health Services, Cohealth, ISIS Primary

Care and EACH. Ms Raskin also presented at the

Australia Centre for Healthcare Governance

conference in Melbourne.

“In Canada we are working hard to maximise

our organisation’s skills, which requires critical thinking

and research. Critique can lead to pride in what you

do; it drives staff development and brings about positive

change, which improves the health outcomes of our

community,” Ms Raskin says.

“We need to be continuously exchanging ideas, learning

and improving our services. This study tour has been

a great opportunity to share with people committed to

caring for their communities, through healthcare and

social support.”

The VHA would like to thank the Canadian Association of Community Health Centres, the United States National Association of Community Health Centres and the International Federation of Community Health Centres for helping to facilitate the tour.

US and Canadian community health delegates from left: Bruce Gray, Michelle Jester, Bill Davidson, Simone Thibault, Lynne Raskin,

Hersh Sehdev, Anita Monoian and Doug Smith.

Page 17: Health matters july 2015

17ISSUE 1 [JULY 2015] VHA.ORG.AU

Funded by the Commonwealth and administered by

the Brotherhood of St. Lawrence, HIPPY is a free home-

based literacy and early childhood enrichment program

for preschool children aged four and five. It aims to:

• maximise the chances of a successful early school

experience for children

• empower parents to be their children’s first teacher

• foster parent involvement in school

and community life

• aid children and families who speak another

language at home

The program empowers parents with educational tools,

story books and targeted learning strategies to support

their children in preparation for school.

“HIPPY is one of the most outstanding programs for

ensuring that disadvantaged youngsters get a good

start in school, and that’s because it involves parents

in the process,” Brotherhood of St Laurence Executive

Director Tony Nicholson says.

Since its commencement in 2008, HIPPY Moreland

have had an average of 30 families per two-year cycle

and are currently working with 60 families in Fawkner

and surrounding suburbs. Many of the families come

from India, Pakistan, Sri Lanka and Bangladesh.

HIPPY Moreland has engaged 15 home tutors since

2008 and currently has five home tutors, who between

them speak six different languages; Urdu, Hindi, Punjabi,

Marathi, Tamil, Arabic and English.

“We have seen families successfully complete the

program and have had various parents employed

as HIPPY home tutors after their child’s involvement

in the program,” General Manager, Family and

Community Support Services Tassia Michaleas says.

The benefits for participating children include:

• encouraging a love of learning

• maximising chances of enjoyment and doing

well at school

Merri Community Health Services HIPPY programMerri Community Health Services (MCHS) provides health and social support services to the diverse and culturally rich communities across northern metropolitan Melbourne. Its Home Interaction and Program for Parents and Youngsters (HIPPY) targets disadvantaged children and families in Fawkner and surrounding suburbs.

• promoting language and listening skills and

developing concentration

• building self-esteem and confidence in learning

• improving communication between parents

and children.

Positive outcomes for families include:

• creation of positive learning environments

at home and an overall positive impact on family

relationships

• increasing parents’ knowledge of child

development and the way children learn

• providing parents with opportunities to enjoy

positive time with their children

• enabling parents to be actively involved in their

children’s education

• supporting parents through HIPPY tutors to

develop new friendships and promoting a sense

connectections with their community

• increasing caregivers’ self-confidence in parenting

• creating employment and training opportunities

for caregivers who become home tutors

Page 18: Health matters july 2015

Annual Conference 8-9 October 2015Champions for Change

Please visit vha.org.au/events for information on these and other VHA events

Our 2015 Annual Conference Champions for Change will celebrate the great achievements made by healthcare change agents over the past year.

Keynote Speaker Dr Karen Hitchcock and other health sector leaders will share their change stories to inspire discussion about how we should be servicing our community’s healthcare needs today and tomorrow.

Dr Hitchcock is a staff specialist in acute and general medicine at the Alfred Hospital, holds a PhD in Literature, and is an award-winning writer. In her Quarterly Essay published in The Monthly she writes:

“The elderly, the frail are our society. They are our parents and grandparents, our carers and neighbours, and they are every one of us in the not-too-distant future. They are not a growing cost to be managed, or a burden to be shifted, or a horror to be hidden away, but people whose needs require us to change.”The VHA Annual Conference will be hosted on Thursday 8 and Friday 9 October at the Pullman Melbourne on the Park.

Rural and Regional Forum 6 August 2015Empowering health services and their communities to set the agendaThe VHA will host a Rural and Regional Forum for health and community care professionalson 6 August.

Federation CEO of the Royal Flying Doctor Service of Australia, Martin Laverty, will open this event at the Novotel Forest Resort, Creswick. He will be joined by Chief Executive of Patient Opinion Australia, Michael Greco, and Inner Melbourne Community Legal Senior Project Manager and Lawyer, Linda Gyorki, in a panel Q&A session titled ‘Improving health outside of healthcare’.

Other speakers will include Health Purchasing Victoria Chief Executive Megan Main, Timboon & District Health Service CEO, Gerry Sheehan and Executive Director of Residential and Clinical Governance Services at Ballarat Health Services, Sue Gervasoni.