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