Kidney Health Australia

Victoria 125 Cecil Street South Melbourne VIC 3205 GPO Box 9993 Melbourne VIC 3001 www.kidney.org.au vic@kidney.org.au Telephone 03 9674 4300 Facsimile 03 9686 7289 Submission to the Primary Health Care Advisory Group Better outcomes for people with chronic and complex health conditions through primary care Kidney Health Australia September 2015

What is the problem? What aspects of the primary health system work well for people with chronic and complex conditions? What is the most serious gap in the primary health care system currently provided to people with chronic and complex health conditions? Recommendation 1: Include the Integrated Health Check for early detection of chronic kidney disease as part of a new dedicated MBS item and/or a blended payment, supported by the proposed quality focussed Practice Incentive Payment for general practice Chronic kidney disease (CKD), diabetes, heart disease and stroke together account for approximately onequarter of the disease burden in Australia and two thirds of all deaths. Translated into human terms, this means that every hour, five Australians die from one of these conditions. These diseases are collectively referred to as vascular disease due to the damage they cause to blood vessels and the heart. Vascular and related diseases are considered the most costly to Australians, both in terms of health expenditure and in the burden of disease, measured in terms of disability and premature death. There are serious gaps in the implementation of best-practice early detection and management practices of these commonly experienced chronic diseases. These diseases often arise from similar underlying causes, share a number of management and treatment strategies and are also largely preventable. There is potential to reduce the associated burden of CKD, cardiovascular disease (CVD) and diabetes comorbidity by controlling common risk factors and improving disease management. Effective prevention and management of one condition can lead to reduction in the risk of related disease. CKD is a major health problem, and one that is growing. Without greater focus from the Australian Government, there is clear evidence based on current trends that the situation has the potential to worsen. Kidney Health Australia (KHA) estimates that 1 in 3 Australians are at an increased risk of developing CKD. Approximately 1.7 million Australians a striking 1 in 10 over the age of 18 years have at least one clinical sign of CKD. And the situation is much worse for at risk groups. The burden of CKD is distributed unequally and unfairly, as evidenced by the high rates of the condition in the lower socio-economic groups and in the Aboriginal and Torres Strait Islander community. Recent economic analyses show that individuals with CKD incur 85% higher healthcare costs and 50% higher government subsidies than individuals who do not have CKD. Based on an estimated prevalence of 10% of adult Australians with CKD, the annual additional costs attributable to CKD in Australia is estimated at $3.5 billion. Kidney Health Australia therefore presents this submission with a range of initial suggested actions to help address the increasing burden of CKD. KHA, as part of the National Vascular Disease Prevention Alliance (NVDPA), which also comprises the National Heart Foundation, the National Stroke Foundation and Diabetes Australia advocates for the implementation of the Integrated Health Check through the below steps. 1. Introduction of an Integrated Health Check which includes two major steps: a. GPs check eligible patients for vascular and related conditions through an Integrated Health Check which includes an absolute cardiovascular risk assessment, diabetes check and kidney disease check; b. GPs manage the overall risk profile of patients, stratify risk (high, moderate, low) and address their combined risk factors through advice about healthy eating, healthy physical activity and healthy weight, medical management and/or facilitating and coordinating access to evidencebased prevention programs. 2. The Integrated Health Check be facilitated by a dedicated MBS item, and the ongoing management be supported by the introduction of a blended payment, such as the proposed, quality focussed Practice Incentive Payment (PIP) which would require general practices to: Page 2

a. Maintain a patient register, with a recall and reminder system for patients eligible for assessment and those who require management of risk; b. Incorporate quality improvement by recording and reporting on the proportion of eligible patients who are checked, who have their risk managed according to the relevant practice guidelines, who have a GP management plan, and who access evidence-based prevention programs. 3. The proposed quality PIP be linked to Primary Health Networks, with the Networks charged with promoting uptake of the Integrated Health Check through education, systems support, creating linkages with relevant prevention services in the Network, measurement, and reporting and evaluation via quality improvement audits. 4. The proposed PIP adopt some of the existing functions from current PIPs, noting that they share commonalities in operation and that this would also streamline both the administration and operation of current PIP arrangements. 5. Commitment to continue funding for a second biomedical survey, a key component of the Australian Health Survey. A new MBS Item and/or blended payment, supported by a quality-focussed PIP, would complement existing PIPs and encourage general practice to implement an Integrated Health Check for the early detection and risk management of people at increased risk of developing CKD, type 2 diabetes, heart disease or stroke. The Integrated Health Check would link into already existing systems. For example, it would form an integral part of chronic disease management as an entrance point into the current Chronic Disease Management Plan mechanism. This integrated approach to detection and prevention of vascular and related disease incorporates the recommendations of existing guidelines and policies of the National Health and Medical Research. The detail behind this proposal is in the separate submission from the National Vascular Disease Prevention Alliance (NVDPA), of which Kidney Health Australia is a member, and which has been lodged with the review. Page 3

Patient care Do you support patient enrolment with a health care home for people with chronic and complex health conditions? What are the key aspects of effective coordinated patient care? KHA supports models that encourage equitable access to continuous coordinated care for all Australians. Key aspects of effective coordinated patient care include evidence-based prevention, early detection and management of chronic conditions and their comorbidities that is adequately reimbursed as part of normal clinical care. Care planning needs to be attached to outcome measures and strongly linked to ongoing review. Recommendation 2: Implement integrated Primary Health Care Education that recognises the shared contribution of CKD, diabetes and cardiovascular disease Coordinated patient care and management needs to be supported by ongoing health professional education. Primary health care providers need to be supported with integrated Primary Health Care Education that recognises the shared contribution of CKD, diabetes and cardiovascular disease and the corresponding management of these comorbidities. A recent report indicated that within general practice in Australia, there are significant shortfalls in the recording of kidney function and the recorded prescribing of appropriate kidney protective therapy.7 Furthermore, the AusHeart study recently concluded that CKD is common, significantly under-recognised and under-treated in primary care. Yet research has highlighted that the most sustainable and likely the most cost-efficient model appears to be opportunistic general practice screening. KHA through its existing Kidney Check Australia Taskforce (KCAT) program, in collaboration with Primary Health Networks is well positioned to roll out a national Integrated Primary Health Care Education program to support the increase in targeted screening of at risk patients through an Integrated Health Check approach. KHA has a proven track record in this area, with the successful rollout of the federal government funded national education program to support the implementation of automatic reporting of estimated glomerular filtration rate in primary care. The KCAT program, the only one of its kind in Australia, seeks to educate health professionals in primary care on the advances in knowledge in early detection and management of CKD and other interrelated chronic diseases. This program with limited funds to date, has focussed its educational effort on face to face workshops, on-line learning and written material. The KCAT modules are run as interactive learning sessions aiming to improve the knowledge, detection and management of kidney disease in general practice. To date, KCAT has educated over twenty five thousand participants through our face-to-face sessions or online education tools. KCAT continues to be the leading voice in kidney education in Australia. KHA is the only organisation offering comprehensive education on kidney disease to health professionals. The education delivered by KHA is exemplary in ensuring it is based on best practice, with all of its educational material developed and approved by the KCAT Committee. This multidisciplinary Committee is comprised of nephrologists, renal nurse practitioners, general practitioners, practice nurses and other relevant allied health and government professionals. KHA through its existing KCAT program and our involvement with the NVDPA is well positioned to rollout an enhanced national Primary Health Care education program that not only supports an increase in the best practice management of CKD and its inter-relationships with CVD and Diabetes, but also the direct uptake of an Integrated Health Check. Page 4

Recommendation 3: Support nurse-led chronic disease clinics to improve best practice management and coordination of care. Nurse-led clinics have proven effective in successfully coordinating care for patients with CKD, through increased detection, earlier intervention and improved management in general practice, and development of clear pathways to specialist medical care where indicated. Evidence of this model working is highlighted by the project implemented by the then South Eastern Melbourne Medicare Local. This organisation identified CKD as a priority health concern and with their key partner, Monash Health, collaborated to design an innovative coordinated disease management approach. The aim of the project was to establish nurse led CKD clinics in the primary care setting to: Facilitate leadership opportunities for practice nurses (PN). Improve collaboration and integration across health sectors. Embed evidence based resources for screening, diagnosis and management in primary care. Utilise practice nurse clinical expertise to coordinate care with the GP for early risk factor identification, CKD screening and management when indicated. The first nurse led clinic was established in September 2014. The clinic model includes screening at risk patients, staging for CKD, and implementation of an appropriate management plan. Preliminary results demonstrate a steady growth in patients diagnosed with CKD and facilitated improved management. The clinic model has promoted better identification and coordination of care for patients with, or at risk of CKD. The nurse led model has created leadership opportunities within general practice and supported more effective, efficient and accessible service delivery. Strong leadership opportunities for practice nurses have been created. Utilising evidence based guidelines, practice software and clinical expertise, sustainable change is being embedded into general practice. Practice nurses are actively facilitating better linkages and integration between health care providers and services. Recommendation 4: Implement self-management programs that support consumer awareness, skill development and coaching It is imperative that Primary Care Networks partner with key organisations to implement projects and programs that support consumers to navigate the system and equip consumers with self-management skills, support and resources. In regards to chronic kidney disease, there is a clear need for a comprehensive kidney education program that focuses on delivering self-management education for people living with kidney disease. There is also increasing demand for an enhanced service to provide information, clarify issues and help people through the emotional journey of living with kidney disease, and understanding its impact on lifestyle and family with practical information and pathway suggestions. Many of the mechanisms to enable greater self-care by patients exist already having been trialled and proven. In many cases, they simply need the recognition and funding to enable them to be rolled out nationally, so that all Australians living with chronic disease can access low cost resources that will empower them to better care for themselves. KHA is well placed to provide assistance in this regard, having developed and implemented models here in Australia. KHA has developed the My Kidneys, My Choice decision aid program. This program developed a shared decision making process for those with end stage kidney disease, with the key aim to ensure that patients knew about all of their treatment options and were involved in the decision making process. The program was developed with support from the Department of Health s Chronic Disease Flexible Funds, and includes extensive resources for the patient, covering: Lifestyle, Treatment Options, Training and Support, Page 5

Diet, Costs and Travel issues, as they related to ongoing end stage kidney disease treatment. The program has been extensively evaluated and is considered a successful model, recently being published in the Clinical Kidney Journal, development was supported by involvement of Monash Health Nephrology Nurse Practitioner. KHA is also currently piloting a My Kidney Journey self-management program for people with early stages of kidney disease. This initiative complements the Integrated Health Check by ensuring that when people are identified with kidney disease early in the disease trajectory they have access to information, resources, and services that can equip them with the skills to prevent the progression of kidney disease. Evaluation of this project will take place in early 2016. Page 6

Use of technology How might the technology described in Theme 2 improve the way patients engage in and manage their own health care? What enablers are needed to support an increased use of the technology described in Theme 2 of the Discussion Paper to improve team based care for people with chronic and complex health conditions? Recommendation 5: Develop electronic support tools to support decision making and integration of care in general practice. The development of more integrated support tools and mechanisms is necessary to support ongoing and sustainable change in practice. Electronic decision support pathways software programs, developed as part of the emap CKD program in Victoria can integrate with primary care electronic health records, allowing real-time prompting for CKD risk factor identification, testing, diagnosis and management of CKD according to Kidney Health Australia s best practice recommendations. Results from a pilot study indicate improvement in CKD risk factor recognition, complete testing for CKD, entry of a diagnosis of CKD into the electronic health record and an improvement on CKD patients achieving each of KHA s recommended management targets. The success of this pilot program has encouraging implications for use across the primary care community as a whole. Electronic tools such as HealthPathways are also being developed as a means of integrating patient care between all relevant health providers at the level of the individual patient and their current health problem. The HealthPathways project is innovative in the Australian context, although it builds on earlier experience in New Zealand. A similar program, Map of Medicine, is successfully operating in the UK National Health Service. Each HealthPathway starts with a particular health problem and defines a pathway for its management that reflects evidence-based best practice in the context of locally available resources and facilities. The process of developing a locally-defined HealthPathway ensures ownership and 'buy-in' by local clinicians, and may lead to new solutions as clinicians work across the hospital-community interface perhaps for the first time. Computer systems and electronic support tools have long been promoted for their potential to improve the detection of conditions and quality of healthcare. Ongoing support to general practices to improve data quality and interrogate risk factor data, implement electronic support tools and integrated pathways is important if chronic disease management is to be effective and efficient. Further investment in decision support tools is critical to enabling patients to engage in their own health care and supporting team based management of chronic conditions. Page 7

Evaluating system performance Reflecting on Theme 3, is it important to measure and report patient health outcomes? To what extent should patients be responsible for their own health outcomes? Recommendation 6: Funding for a second biomedical survey to support evaluation and performance measurement. Monitoring and evaluation are essential for measuring progress in disease reduction. There are two areas of importance in monitoring the effectiveness of interventions. Firstly, it is essential to understand the quality of care received by people with chronic diseases from their medical practitioner. This information can be used as part of a continuous quality improvement process where general practices audit their activities against guidelines and targets. This helps to ensure adherence to clinical practice guidelines and support better patient outcomes. Secondly, national health measure data is essential in providing decision makers, health professionals and researchers with an understanding of the status of the key diseases and risk factors. Measuring the impact of health interventions allows governments to ensure the most effective use of limited resources. The first Australian Health Survey (2011-13), with critical biomedical data coming from the National Health Measures Survey a biomedical survey has been the most comprehensive health survey ever conducted in Australia. It has collected information such as health status, behavioural risk factors (e.g. smoking, physical inactivity), service use, medications, and the prevalence of biomedical risk factors, such as high blood pressure, high blood cholesterol and overweight/obesity. It is important that this survey be repeated every 5-6 years, to ensure timely information to support policy decisions. The cost of the survey is minimal compared to the cost of the chronic disease burden. Failure to continue investment in the survey, especially the biomedical component, would lead to sub-optimal investment of resources (waste and inefficiency) and poorer health outcomes for Australians. Page 8

Payment models How should primary health care payment models support a connected care system? What role could Private Health Insurance have in managing people with chronic and complex health conditions in primary health care? As discussed earlier, the proposed PIP, would complement existing PIPs and encourage general practice to implement an Integrated Health Check (as would the dedicated MBS item) for the early detection and risk management of people at increased risk of developing chronic kidney disease, type 2 diabetes, heart disease or stroke and their ongoing management. The quality-focussed PIP would include two major areas of activity: i. Patient register, recall and reminder system As with the existing PIPs, general practices would be required to establish and maintain patient registers, with recall and reminder systems to ensure that eligible patients are systematically identified and notified of the need for assessment or management of risk factors. Use of one system for the integrated health check provides greater efficiencies for general practices. ii. Incorporation of quality improvement Quality improvement can be incorporated into this PIP through setting targets and conducting audits of records to monitor the proportion of eligible patients who receive an integrated health check or who have their risk managed according to guidelines or who are participating in evidence-based lifestyle management programs according to their GP Management Plan. Targets could also be set to ensure that patients at low risk are informed and educated about risk factors and the lifestyle changes they can make to reduce their risk of future vascular and related disease. KHA believes that introduction of a new quality PIP provides an opportunity to streamline current arrangements and reduce red tape, both for Government and for practices. This could be achieved by amalgamating similar PIPs, and building in the ongoing management that stems from an Integrated Health Check. Specifically: GPs / Practices will no longer have to use a number of separate codes for different PIP payments, an issue that GPs report has resulted in reduced uptake of a number of PIP payments; It will be administratively simpler for Government, as it will no longer need to administer multiple PIP payment submissions for practices; The Integrated Health Check will provide a seamless entry point for GPs to identify which patients would most benefit from existing mechanisms such as the Chronic Disease Management Plan; and Audit of patient records including use of the Chronic Disease Management Plan will provide important data to support continuous quality improvement. Data collection can include numbers of eligible patients assessed, numbers managed according to guidelines and numbers participating in lifestyle programs A very important mechanism in supporting quality clinical practice is the use of focussed financial incentives. A conglomeration of existing PIPs into a single quality reward is a way of assisting Primary Care in managing chronic disease in a more efficient way. A dedicated MBS item number will help drive uptake from currently low levels. It will assist in the reform of general practice along the lines of contemporary evidence based guidelines, coordinate the care given to those with chronic disease and provide a rich, more detailed data source for care analysis and improvement. Not only will this support a more efficient multidisciplinary care model, it will more importantly lead to greater person centred care. Page 9