1. An Alternative Model of Care Dr Anna Ranta Consultant Neurologist MCDHB Associate Dean University of Otago

2. The Waitlist Problem Dr Anna Ranta Consultant Neurologist MCDHB Associate Dean University of Otago

3. Overview Background Improvement Strategies Nested within Secondary Care Nested at Primary/Secondary Interface Show casing Non-Contact Specialist Assessments Lessons Learned and the Way Forward

4. Why did we bother? Born out of necessity 2 year wait lists Some patients never seen Non-transparent prioritisation Poor follow up and high DNA rates Poor Team Morale Clinician versus Manager

5. What did we do? Consider, understand, and own the problem as a TEAM: Numbers on wait list by priority Numbers seen each month Numbers referred each month Deal with backlog to stop drowning Determine and increase capacity Consider ‘Alternative Models’

7. Solutions: Secondary Care Delegate/empower team members: Neuro RN phone/email advice Technician education and reporting Nurse education and clinics MDTs Close relationship with manager to write business cases and manage budgets

8. Solutions: Primary Care GP Education and Engagement Teaching (peer review) Guidelines, publications, and audits Clinic letters, emails, phone advice GP empowered w/ specialist back-up Access to diagnostics (e.g. CT headache) Electronic decision support (e.g.TIA) Limiting follow-up (Non-contact Clinics)

9. When capacity is reached: Non-contact clinics Aka ‘Virtual’ Clinics’ (FSA and FU) Origins in reluctance to ‘simply turn patients away’ Not an alternative to face-to-face assessments, but as an alternative to NO assessments Tracked, counted, and now funded

10. What does it entail? Referrer writes to specialist Patients who are anticipated to (a) likely wait more than 6 months (b) have simple problems better served with quick written response (c) needing primarily an investigation  Triaged into “NC-FSA”

11. Then what? Prior specialist letters and other relevant documentation/diagnostics reviewed Some additional diagnostics accessed through secondary care Management plan created to be implemented in primary care  Formal letter written to GP/referrer w/ option to re-refer

12. What is the cost? Face-to-face = 45 min NC-FSA = 15 min Funded at 1/3 regular FSA Now offering NC-FU (not funded) Other similar activities not funded: RN calls/emails and education Staff education ‘Curb side’ consults

13. NC-FSA Audit Data July 2008 – August 2009 1,107 referrals 802 (72.5%) face- to-face clinic 222 (20%) NCFSA 5 (2.3%) re- referred at one month 25 (11.3%)re- referred at 6 months 4 (1.8%) admitted at one month 13 (5.9%) admitted at 6 months 83 (7.5%) returned/forwarded

14. Adverse events 3 (1.35%) delays in dx 1 (0.45%) detriment no permanent disability

15. Referral Details (n=222)

16. GP Feedback (n=47) Q1 Did you find the advice helpful in terms of probable diagnosis, management, or simple reassurance? Q2 Did you share the specialist opinion from "non-contact assessments" (virtual clinics) with the patients? Q3 Did you have difficulty when the neurologist said the patient couldn't be seen but advice was provided in writing? Q4 Do you think treating patients via specialist written advice when they cannot be seen within 6 months improves patient care? Q5 If a patient cannot be seen by the neurologist because of lack of resources, would you rather have the referral returned without advice? Q6 Would you rather patients wait longer than 6 months but eventually see the neurologist? 131 surveys sent out, 47 replies received, where % do not add to 100% remainder did not answer question

17. Overall Benefits All patients referred receive a specialist opinion Wait times improved (>2yrs  3-6months) Better primary/secondary interface Empowered yet supported GPs More inter-collegial trust Up-skilled GPs Care closer to home for patient and often achieved faster

18. Lessons Learned Emphasise: Not instead of face-to- face, but instead of no care Born out of necessity and not a panacea, but a unexpected positives Specialist the hardest to convince Patient/referrer expectations need to be managed, but minor hurdle

19. The Price of Increased Efficiency Traditional model of ‘letting wait list grow’ alive and well Blame management; need more $ Inequities across services Specialist Training at risk Specialist Existence at risk? Specialist Burn-out?

20. The ‘Alternative’ Model Rethinking Specialists role: Shift some specialist resource away from face-to-face patient contact More emphasis on: Education, supervision, and support Team approach (within/across sectors) Population Health & Clinical Leadership Ideally Hospital/DHB/region wide with less focus on our own specialties

21. Next Steps Efficiency to be promoted through appropriate rewards/incentives Funding stream adaptation to properly recognise/fund ‘non-contact’ time More clinician engagement to ensure safety: work with not against management Public perception to be further shaped to understand and accept limitations  Strive for good and equitable care across specialties, sectors, and DHBs

22. Summary YES, there is a resource problem And NO it is not going to go away BUT in NZ we are well ahead of the game A bit of ‘can do’ attitude goes a long way ‘Can do’ teams with ‘can do’ leaders and ‘can do’ managers even better…. In my mind the goal is to achieve comprehensive, conscientious, and equitable health care to our entire population

23. QUESTIONS?