health matters july 2015
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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
THE VICTORIAN HEALTHCARE ASSOCIATION2
8 Community health left to treat fallout from trauma
6 When should we mobilisepatients after stroke?
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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
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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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
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
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.
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.
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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
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
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
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
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
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
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.
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
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.
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
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.