Planners ForumMelbourne 2011

Nicole Cameron

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Current Situation Department of Health

New CE formation of Department of Families

Health Reform – opportunity for change Structural changes underway – staged approach Only at the beginning (11 April 2011)

Service Planning Historically more of a ‘silo’ approach Need for integrated planning (continuum/ clinical/ infrastructure) Likely an official Departmental Planning Unit will be established Meanwhile work is underway…

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Northern Territory – it IS special! Population Context

Large geographical mass sparsely populated Small resident population with historically younger profile 30% Indigenous people (2.4% Nationally) 70% Indigenous people live in remote/ very remote areas Greater proportion of Low SEIFA values than any other jurisdiction

Population Health (BOD) Lower life expectancy than any other jurisdiction Highest BOD amongst all jurisdictions NT indigenous BOD 3.57 times higher than national average NT non-indigenous BOD 1.22 times greater

Activity Small proportion of population account for high usage of services ASH - Over 66% inpatient Indigenous & over 80% ED presentations

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From today… Political Context

Close political environment Territory 2030 – strategic direction for major services

Health services will be easier to access for all Access to services will be at a similar level as other states New Hospital in Darwin

Multiple stakeholders (AMSANT/ GPNNT/ Remote)

Have commenced integrated planning (noting last point) Challenge for the NT:

‘Purist’ influence - service planning technical tools Pragmatic approach – in the NT context Creative implementation – multiple challenges (often conflicting)

but necessary to think differently and apply national and international learnings to meet these ‘special’ needs

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RENAL SERVICES IN THE NT

Creativity in implementation

An example for today:

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The Problem High Chronic Disease and increasing ESKD Majority from remote community (85% all dialysis patient

are Indigenous people) Centralised service provision

Poor access to health services Limited access to specialists

Poor management of CKD Prior to CTG/ intervention

Poor psychosocial preparation for treatment

We needed to think creatively in the context of the Territory, the patient and also of best practice

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Growth Industry

NT Prevalence ESRD 1997 - 2009

0

100

200

300

400

500

600CA TE Total

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Growth in Renal Replacement Therapy

NT Dialysis Treatments 1993 - 2009

0

10000

20000

30000

40000

50000

60000

Tre

atm

ent

Nu

mb

ers

CA TE Total

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Modality Uptake

NT Renal Replacement Therapy 1997 - 2009

0

100

200

300

400

500

600

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Pat

ient

Num

bers

HD

PD

Tx

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Projected Treatment Modality UptakeProjected ESRD Prevalence According to Treatment

Modality

-

100

200

300

400

500

600

700

800

900

Patie

nt N

umbe

rs

Transplant

Home HD

Sat HD

Hosp HD

CAPD

APD

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Community of Origin

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Focus of NT Renal Services New Strategy and Service Plan Development

Coordination with Remote Health DCI, AMSANTS, AG and NGO

Improved Care Coordination - identification and case management Public Health RN and IT integration Case Conferencing and Outreach CKD clinics Resources All options available (palliative care/ renal project)

Decentralise and decrease demand for satellite services Supported PD – hostel accommodation (Mid 2011) Home and community based HD (self care – relocatables/ RRR) Smaller regional facilities

Finding viable solutions Supporting people to be independent in their care Opportunities for treatment closer to home (reverse respite/ renal bus)

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Building in Program Flexibility

Simple systems Safely contained Easily maintained by client Minimal need for intervention (promote independence)

Infrastructure Client’s home

Renal Ready Rooms Aged Care Centres

Relocatables

#3x3 area

#1 chair up to 4 people#Capacity for 1 or 2 chairs

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Training Agreement Client responsible for treatment Client agrees to attend all training sessions Client trains partner Competency Checklists

Interpreters

Community Consultation (up to 3 visits) Community Health Centre Staff

Local Shire Staff and store managers if required

Community Partnership Agreements

Client and Staff Support Hot Line

Regular site visits

Training Program

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GROOTE EYLANDT

TIWI ISLANDSHome Training Unit

Darwin and Alice Springs – 2 stations

Relocatable - 2 station, Galiwinku, Maningrida, Milingimbi, Angurugu, Borroloola, Amoonguna, Ti Tree, Ali Curung ,Oenpelli, Ngukurr, Barunga, Lake Nash

Home situation – Darwin x 3 Wadeye x 1 station

Renal Ready Room – 1 station Nguiu, Ramingining, Yirrkala, Kalkarindji, Mt Liebig, Santa Teresa

WDNWPT Reverse respite - 2 stations –A/Springs, Yuendemu, Ntaria and Kintore

Renal Ready Room – 2 station, Gove

Proposed new sites – Milingimbi, Wadeye, Maningrida,

Community-based Home HD Services

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GROOTE EYLANDT

TIWI ISLANDS

Peritoneal Dialysis Patients

CAPD

APD

Patients in TE = 28

Urban and rural Darwin, Katherine, Jabiru, Timber Creek, Kalkarindji, Pigeon Hole, Palumpa, Jilkminggan, Beswick, Ngukurr, Gapuwiyak, Gove, Yirrkala, Milingimbi and Maningrida

Patients in CA =10

Alice Springs x 6, Tennant Creek x 2, Kiwirrkurra x 1, Santa Teresa x 1

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Waste Management in Remote Areas Remote community waste

directed to land fill

Each HHD patient generates 1 bin every 4-6 weeks.

Removal of biohazard waste

Tracking and management resource intense

Biohazard waste management legislation

Need a new management strategy

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Introduction of Turboburner

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Turbo Burner Requirements

200L drum in reasonable condition to ensure a snug fit of

the turbo burner lid.

Weatherproof storage facility due to electrical components

Wood/cardboard/old oil or substitute combustible to

achieve the best burn

Requires the management (loading, lighting, storing) to be

allocated

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After burn

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Outcomes

Complete burn of medical waste with minimal accelerants (waste oil or diesel)

Produced a smoke free and odourless burn

No hazardous gas emissions

A preferable option of disposing of dialysate waste to landfill

A more cost effective option than removing waste from communities

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GROOTE EYLANDT

TIWI ISLANDS

Galiwinku,

Maningrida,

Milingimbi,

Angurugu,

Borroloola,

Amoonguna,

Ali Curung ,

Ngukurr,

Barunga,

Lake Nash

Nguiu,

Wadeye

Santa Teresa

Yuendumu,

Ntaria

Kintore ,

Mt Leibig

Turbo burner Locations

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Western Desert Nganampa Walytja Palyantjaku Tjutaku (WNDWPT)

Reverse Respite Program – non-gov service delivery model Supported through funding from sales of art and mining royalties Supported by a board of elders from the Kintore region and a separate

board from Yuendumu (providing own funds, under the guidance of WDNWPT)

Alice Springs location at the Purple house providing Social support, advocacy, PHC services, self care training and respite dialysis

Nurse assisted dialysis and Return to Country trips provided: Kintore Yuendumu Hermannsburg

Nurses employed under a private contract arrangement

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Requirements for Community Dialysis

NT Renal Services has a SLA with WDNWPT to support with machines and chairs to provide reverse respite.

WDNWPT ensure clients: have clearance from the Nephrologist to be dialysed away from the

Renal unit trip is planned (ie you can’t turn up at your community dialysis facility

and expect to be dialysed) have family support for your visit have been going regularly to dialysis, taking meds to be considered

for a trip home Who miss scheduled dialysis out bush are returned to town WDNWPT is responsible for the dialysis care of the patient.

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Renal Indigenous Resources

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Renal Indigenous Resources

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Mobile Bus Feasibility - Service Gap Limited rural satellite units and limited placements

Tiwi Dialysis Centre – fly in fly out basis, difficult to expand Katherine Dialysis Unit – most from surrounding regions, issues of

relocation Tennant Creek Dialysis Unit – at capacity

Self-care Therapies Home HD - growing but long training periods, self-reliance

important, infrastructure rollout slow and costly Peritoneal Dialysis – uptake improving but ‘churn’ high Resistance from community relating to poor perceptions of RRT Disincentive of staffed facilities

Patient Personal Capacity Many patients will never attain self-care status Reliance on ‘partners’ – spectacularly unsuccessful

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Opportunity for Improvement

Psychosocial maintenance of relationships with kin and country, Enable important events to be attended safely – community

business, funerals, festivals

Improved morbidity and mortality Reduce acute care costs

medical evacuation events, decrease hospitalisations

Increase opportunities for education around renal disease Opportunity to change community perceptions Increase opportunities to attract and retain staff

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Dialysis Bus Floor Plan

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Comparison of Models - Capital

Requirements Reverse Respite Model - One community

Mobile Dialysis Service- Multiple communities

2 station facility $350K $340K

Nurses Accommodation $550K included

Vehicle $75K included

Fencing/office Equipment $20k $5k

TOTAL $995K $345K

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Pros and Cons of Mobile Service Benefits

Can provide respite dialysis to a broad range of communities Infrastructure and recurrent costs are lower Can be utilised to provide education and undertake clinics Is self-contained with minimal impact on community Only requires access to water High interest in service implementation (recruitment)

Risks Robustness of dialysis machinery over un-graded roads untested Continuous access to water maybe an issue Will need time to work out teething problems Space configuration for dialysis, sleeping and living yet to be

tested

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Ali Curung Visit

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THANK YOU