1. Planners Forum Melbourne 2011 Nicole Cameron

2. 2 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…

3. 3 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

4. 4 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

5. 5 RENAL SERVICES IN THE NT Creativity in implementation An example for today:

6. 6 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

7. 7 Growth Industry

8. 8 Growth in Renal Replacement Therapy

9. 9 Modality Uptake

10. 10 Projected Treatment Modality Uptake

11. 11 Community of Origin

12. 12 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)

13. 13 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

14. 14 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

15. 15 GROOTE EYLANDT TIWI ISLANDS Home 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

16. 16 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

17. 17 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

18. 18 Introduction of Turboburner

19. 19 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

20. 20 After burn

21. 21 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

22. 22 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

23. 23 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

24. 24 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.

25. 25 Renal Indigenous Resources

26. 26 Renal Indigenous Resources

27. 27 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

28. 28 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

29. 29 Dialysis Bus Floor Plan

30. 30 Comparison of Models - Capital RequirementsReverse Respite Model - One community Mobile Dialysis Service - Multiple communities 2 station facility$350K$340K Nurses Accommodation$550Kincluded Vehicle$75Kincluded Fencing/office Equipment$20k$5k TOTAL$995K$345K

31. 31 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

32. 32

33. 33

34. 34

35. 35

36. 36 Ali Curung Visit

37. 37

38. 38

39. 39 THANK YOU