PRESENTERS JENNY CUTTER KIMBERLEY RENAL SERVICES MANAGER & AMANDA ELZINI KUNUNURRA/FITZROY CROSSING RENAL HEALTH CENTRE MANAGER
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1 ta PRESENTERS JENNY CUTTER KIMBERLEY RENAL SERVICES MANAGER & AMANDA ELZINI KUNUNURRA/FITZROY CROSSING RENAL HEALTH CENTRE MANAGER
2 OVERVIEW INTRODUCTION TO THE KIMBERLEY ABORIGINAL MEDICAL SERVICE LTD AND KIMBERLEY RENAL SERVICES PTY WHO WE ARE AND WHAT WE DO HOW THE KRS CARES FOR RENAL PATIENTS IN THE KIMBERLEY
3 PHILOSOPHY The association has been established by Aboriginal people for Aboriginal people. Empowerment in illness prevention, health promotion, planning and service delivery requires participation in decision making by Aboriginal people from the communities they serve. VISION STATEMENT The Kimberley Aboriginal Medical Services (KAMS) is managed and controlled by Kimberley Aboriginal people and is locally and nationally recognised as a leader in the provision and support of holistic and culturally appropriate comprehensive primary health care services for Aboriginal people. MISSION STATEMENT KAMS exists as a responsible Aboriginal Community Controlled Council to improve Aboriginal health in the Kimberley region of Western Australia by providing continually improving essential cooperative services along with a unified voice and representation for existing and developing comprehensive primary health care services and community health services. In achieving its Mission KAMS will: Provide Aboriginal Community Controlled Health Services (ACCHS)essential centralised services, which are not otherwise available to them. Contribute to policy development and representation at a community (community clinic), district (ACCHS, regional (KAMS), State (AHCWA) and national (NACCHO). Regularly monitor and report its achievements in improving Aboriginal health. Provide a single and accepted voice which re[resents all of its Kimberley Aboriginal constituents. Be accountable in all of its dealings with its co-operative Board members and other stakeholders. An Organisation of Aboriginal people, for Aboriginal people controlled by Aboriginal people.
4 THE KIMBERLEY
5 KIMBERLEY RENAL SERVICES PTY
6 October 2014 KRS became a company in its own right. Nearly 63 staff on the payroll. Have infrastructure in Broome, Derby, Fitzroy Crossing and Kununurra. Also operate the Mobile Dialysis Unit
7 Aboriginal Health Workers CLINICAL STAFF Renal General Practitioners Registered & Enrolled Nurses Aboriginal Care Coordinators Patient Care Assistants Social Worker
8 NON CLINICAL STAFF KRS Manager Renal Unit Managers Business Manager Quality Coordinator
9 KIMBERLEY RENAL SERVICES PTY
10 WHAT NOW FOR KRS A review of the renal service was conducted in April Identified gaps in the service. Services being delivered on a visiting model service not working. Staff having to travel to different areas meant limited time on the ground to provide the support and education required. Translating into poor outcomes for patients in the region.
11 WHAT DO WE KNOW KRS the work that has been done over many years have recognised and documented the high rates of renal disease in the region in the region with some form of renal disease, this figure is under reported. Recorded 95 people in the region in Stage 4 5 Kidney disease who will require renal replacement therapy in the next months Rising numbers throughout the region.
12 TIME FOR CHANGE-WHAT WE DID We looked at what we had. Identified that particular areas of the service were inefficient. Asked people what they wanted rather than what we thought they needed. Working on a Model of Care that was 10 years old. No longer fitted into what was required in the region.
13 KIMBERLEY RENAL SERVICES PTY
14
15 KIMBERLEY RENAL SERVICES PTY
16 GROWTH OF THE SERVICE
17 WHERE TO NOW?
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19 DISTRIBUTION OF TREATMENT MODALITIES CURRENT PATIENT MODE OF TREATMENT SATELLITE DIALYSIS (107) HOME HAEMODIALYSIS (6) TRANSPLANT (12) PERITONEAL DIALYSIS (6)
20 Broome RENAL HEALTH CENTRES Derby Fitzroy Crossing Kununurra
21 Nurse lead units RENAL HEALTH CENTRES Renal GP based in Broome & Derby FIFO support to Kununurra and FX Primary Care supported by local Aboriginal Medical Services
22 HOME THERAPIES Currently 6 patients on HHD in the Kimberley Currently 6 patients on Peritoneal Dialysis Fresenius Medical Care have the WA contract to provide this service
23 HOME THERAPIES- THE GAP Would like to bring this contract back under KRS so patients don't have to return to Perth for 3 months of training Push for patients to take this option of care to ensure the patients who are unable to can come back home also
24 TRANSPLANT COORDINATOR Transplant is not suited for everyone There are 12 patients living in the Kimberley with a transplanted kidney They are supported by the transplant coordinator, nephrologist and primary health care provider
25
26 CHRONIC KIDNEY DISEASE EDUCATORS CKD 1 & 2 CKD 3 EAST WEST
27 CHRONIC KIDNEY DISEASE EDUCATORS One registered nurse in Broome, Derby & Kununurra Responsible for Stage 1,2 & 3 of Chronic Kidney Disease Work in conjunction with and to support the Primary Health Care Provider
28 PRE DIALYSIS/ACCESS COORDINATOR Responsible for Stages 4 & 5 of Kidney disease Monitors decline of kidney function with aim to slow the progression Organises vascular access Prepares the patient for dialysis
29 PRE DIALYSIS/ACCESS COORDINATOR WEST EAST Column1 5 0 STAGE 4 STAGE 5 PALLIATIVE START IN MONTHS
30 MOBILE DIALYSIS UNIT-BRINGING PEOPLE BACK TO COUNTRY Dialyse up to 4 patients/day 2 Machines (+ 1 spare) Communities where the MDU can access: Bidgyadanga Balgo/ Billiluna/ Mulan Fitzroy Crossing region (includes communities) Halls Creek Looma Dampier Peninsula Warmun Wyndham Noonkanbah Wangkatjungka
31 PATIENTS WAITING In January 2013, Perth hosted 32 pts for dialysis treatment. With the opening of FX, Derby and Kununurra, there are currently only 8 patients waiting to come home. However, reality is the number is growing again as our Kimberley Units are getting towards capacity. Major focus for 2016 and beyond- Preventing people needing Dialysis!
32 STOP THE PROGRESSION OF RENAL DISEASE IN THE KIMBERLEY To provide a first class service delivering all aspects of renal healthcare in the Kimberley. To provide support and education to prevent, detect and manage the effects of renal disease on clients. To educate local health professionals in best practice management through the use of chronic disease protocols mainly proteinuria and chronic kidney disease. To work in collaboration with local primary and secondary health care services. To conduct business ethically and demonstrate leadership, in satisfying our responsibilities to our community.
33 Identified that services are best delivered in the communities, rather than a visiting service being provided. Recent restructure of the KRS has enabled us to place key positions in the Renal Health Centres. Key stakeholders will now have better access to vital services which will help them to manage those people with renal disease.
34 A team of renal experts, working in collaboration with local primary and secondary health care services to drive improvements in the management of renal clients. Strengthening health staffs renal knowledge and skill through ongoing education, training and onsite support, around awareness, prevention and early detection and management of kidney disease.
35
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