https://www.abc.net.au/news/2019-12-09/aged-care-royal-commission-continues-in-canberra/11777870
PartridgeGP and Dr Nick Tellis are proud to serve our older Australians in Residential Aged Care Facilities. It’s something we will do more of in 2020 – and we will do better 👍🏼
See our thoughts here:
Some more ideas for improvement 🤔
Book yourself or your relatives in an RACF in for an appointment by calling 82953200
And access our new patients in RACF forms right here
Thanks to Dr Michael Clements and NewsGP from the RACGP for highlighting the needs for aged care 👍🏼
Dr Michael Clements
The Government’s recent funding injection has to be specifically targeted to address the problems GPs, staff and patients face within residential aged care facilities, Dr Michael Clements writes.
‘Mrs X was found wandering at night in the carpark, can you please prescribe medication?’
This was how one recent residential aged care facility (RACF) interaction began for me.
After meeting with the staff and ruling out delirium or biochemical causes, and noting a worsening in the behavioural aspects of dementia, I suggested the patient move to the restricted ward or have extra supervision.
But my request was declined due to lack of beds and I was specifically asked, once again, to commence a medication to prevent the patient from wandering.
The situation was clear: under-staffing in this facility led to pressure to prescribe sedative medications that would keep the patient compliant and allow staff to attend to other residents.
Provision of care within RACFs has become more complex and time-consuming as the population ages and rates of dementia rise. Unfortunately, funding models have not kept pace, even as clinical governance requirements in RACFs have increased and nurse autonomy reduced.
This has led to a situation for many GPs who work within RACFs in which countless night-time phone calls, form-signing, box-ticking and compliance measures now form the largest part of their care. It has also led to an overreliance on anti-psychotic medications for the behavioural aspects of dementia, as understaffed facilities come under pressure to medicate their problems away.
GPs have been looking forward to the Royal Commission into Aged Care, Quality and Safety because they, along with RACF staff, have seen cost-cutting measures applied in facilities, with reductions in numbers of trained staff, greater reliance on lower-skilled assistants, and decreased activities and programs.
Staff across the aged care sector want to see better diversionary activities and care services, nursing numbers, and funding to allow GPs to spend more time with patients and their families. This is felt most acutely in rural and regional areas, which are already experiencing aged care staff and GP workforce shortages.
The Federal Government has suggested high prescriptions of anti-psychotic medications in RACFs is a source of the problem, rather than an indicator of a system that is under-resourced to deal with the complex issues of dementia care.
However, the latest promise of extra funding from the Federal Government does nothing to address the reasons behind the increased use of anti-psychotic medications for the behavioural aspects of dementia; it is simply ‘shooting the canary’ and will have no impact on the gas leak in the coalmine the canary has been screaming about for the last five years.
What RACFs need instead is funding targeted towards sufficient numbers of appropriately trained nursing staff, for GPs to provide comprehensive team-based care, and for tertiary services to get out of hospital grounds and into RACFs to work with GPs.
Novel solutions are required to the problems faced in residential aged care, and each facility will need to find one that reflects their community workforce and need.
But some general steps that will be helpful across the board include:
The message should be clear: fund RACFs and GPs in order to enable them to provide the care that is so desperately needed.
Do not shoot the canary.
© 2018 The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807
PartridgeGP and Dr Nick Tellis are doing our best for better aged care in many of our local aged care facilities. We will do more in 2020! Watch this space 👍🏼
Last night on the 730 Report we saw several GPs make the point that fewer GPs are providing care to elderly Australians in Nursing Homes and other Aged Care facilities.
TRACY BOWDEN: Dr Joseph is a strong believer in continuity of care.
DR PETER JOSEPH: For patients, they come in and they don’t have to explain things to you, that happened years ago, because you know it.
You learn what’s going on in the family and how that affects their health.
You can also pick subtle changes.
What are the solutions?
Dr Stephen Dick suggests the following:
The service is not viable financially and is attached with a burden of being on call 24/7, and having to deal with untrained staff triaging patients who are
quite sick with chronic diseases.
The fix:
1. GPs to operate on a salaried basis to service nursing homes, including a callout fee. The FFS model is broken, utterly, utterly broken, when it comes to aged care.
2. Legislated nurse to patient ratios – both RN to patient and carer to patient ratios.
3. Nursing homes to provide an imprest of basic medications, such as antibiotics and opioids, for after hours issues.
4. Pharmacies to be contracted to provide medications for the residents from a nationally standardised medication chart on a capitated basis – NO MORE OWING SCRIPTS.
5. Get an accreditor with teeth to do spot inspections and severe fines for companies that flout the rules. First offence – $50,000 fine. Second offence – $200,000 fine, resident fees non-payable and the CEO of the responsible corporation placed under house arrest until rectified. Third offence – Home shut down, bonds repaid in full to residents within 30 days, and residents to stay bond-free when and if the facility reopens.I guarantee that if a hospital suddenly had to find 80-odd hospital beds they’d find a solution quick smart.
6. Diets to be individualised and supervised by a dietitian and speech pathologist.
7. Responsibility for the nursing home to provide access to physio, OT, speech, podiatry, optometry in addition to DT.
8. Homes to have a standardised kit out of medical equipment, such as a diagnostic set, ECG machine, local anaesthetic and suture material, biopsy sets, and a room with a printer and wireless access to a network so that we can attend without having to bring every. Little. Piece. of equipment.
I suggest some simple rules for Aged Care facilities:
What are your thoughts?
Our team – here for You!
(on Maternity Leave from August 2018)
PartridgeGP is all about professional, comprehensive, and empowering General Practice care by our GPs. When we refer our valued patients for treatment elsewhere we promote the same high standards, values, and communication that we provide. A letter, referral, or phone call is just part of the standard PartridgeGP service – it’s good clinical handover. Dr Nick Tellis recently collaborated with some excellent GPs in writing an article for the Medical Journal of Australia’s online Insight Blog on ways to improve communication during these times and stressing the importance of better clinical handover. It’s another one of the ways PartridgeGP provides Better Healthcare for our valued patients. Read on.
This is the third article in a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group that is based on GP-led learning, peer support and GP advocacy and was originally published at the Medical Journal of Australia (MJA) Insight Blog here.
“PASSING the baton” describes what health care professionals try to achieve as care of patients is transferred between providers in our complex health care systems. The topic of safe and effective clinical handover comes up repeatedly in discussions on GPDU.
It is apparent that the impacts from delayed or poor clinical handover on patient care across the country are significant, under-reported, and have a profoundly negative effect on the care patients receive.
Dropping the baton
First-hand accounts of treatment delays, duplication of testing, medication errors, and unplanned readmissions are frequently discussed by GPs. Recent clinical case discussions have included a patient in palliative care being transferred to a hospice on a Friday afternoon with no clinical handover, and a 3-month delay in the completion of a discharge summary for a truck driver who was admitted with a myocardial function.
The safety concerns related to poor clinical handover are not new: it’s a problem the health care industry and doctors as a profession have been grappling with for decades. Poor clinical handovers are wasteful of limited resources. How can we improve patient outcomes and “drop the baton” less often?
Rules of the game
The National Safety and Quality Health Service Standards (NSQHS) and the Australian Commission on Safety and Quality in Health Care (ACSQHC) define clinical handover as; “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group”. Appropriate clinical handover is a requirement of the NSQHS. The ACSQHC notes the importance of “transition of care” that “ends only when the patient is received into the next clinical setting”. The Australian Council on Healthcare Standards EQuIP National Standard 12, in particular, specifies the planned provision of transfer information, including results of investigations.
Breakdown in the transfer of clinical information has been identified as one of the most important contributing factors in serious adverse events, and is a major preventable cause of patient harm.
Why is clinical handover from hospitals to GPs done so inconsistently for patients transitioning from our major private and public institutions? The benefits of passing the baton smoothly are clear. It’s time to coach the team to get it right.
Timing is everything
Health services continue to debate the appropriate timeframe for communicating with the GP who is continuing the patient’s care. Timeliness of clinical handover is a topic that comes up frequently. Hospital targets for transfer of care communications vary widely. A recent discussion on GPDU identified several targets within one small geographical area, ranging from “at the point of discharge”, “48 hours after discharge” and “5 days after discharge”.
The reality is that few patients leave hospital with an effective clinical handover. Some will be received within the hospital’s current targets; however, many clinical handovers are not received for weeks, months or, as one post highlighted, years after the patient care is transferred. Some never occur.
Many GPs are asking whether these targets are consistent, appropriate, acceptable or safe. A robust discussion took place after GPs were approached to complete a survey that included a question asking what conditions should warrant a discharge summary on discharge, and what the acceptable timeframe for receiving a discharge summary should be.
The overwhelming consensus was that the gold standard should be clinical handover on discharge for all patients. Many were frustrated that this question even needed to be asked. Some GPDU members wondered whether this was a trick question aimed at moving the goalposts further away from quality patient care.
Services promoting clinical handover to GPs on discharge were highlighted. The Sunshine Coast Hospital and Health Service was identified as a provider that was actively trying to effect positive change. They received plaudits from the wider GP community simply by having a discharge summary management policy specifying complete discharge summaries available at the time of patient discharge.
It is well known in GP circles that starting late ensures that you will run late all day. Timely discharge summaries aren’t late. Timing is everything when you want to be a frontrunner.
Don’t fumble the handover
The consensus among GPs is that well timed, efficient, effective and safe clinical handover, at or before the point of transition of care is essential. Alternative strategies risk adverse outcomes. Clinical handover must be a standardised process between clinicians.
Returning to the athletics track, we can see a clear difference between a handover, a throw, and a drop. Highly trained athletes accept nothing less than a smooth handover – nor should highly trained clinicians. Delegating the handover to non-clinicians, including nurses and medical students, is not good enough. Supervision and ongoing coaching of clinicians is vital.
The baton is passed between people not machines
Imagine the difference electronic systems could make to this smooth handover. Sadly, this smooth electronic handover exists only in the imagination.
In the real world, GPs are grappling with being thrown links to hospital electronic records through systems such as “The Viewer”. Investigations are likely to be uploaded (after a delay) to MyHealthRecord. These are raw data, unfiltered and disorganised, and more of a throw than a handover. Being thrown raw data and being expected to catch them in this way is akin to a hospital doctor being given the login to the GP clinic’s patient management system and being expected to extrapolate a referral.
Personal bests are set; medals are won
The late Sir Roger Bannister ran the 4-minute mile and reset the expectations for all that followed him. GPs and their discussions can highlight outstanding clinical handovers and applaud initiatives and hospitals that are doing it right. Feedback and constructive criticism can be passed back to hospitals that are raising the bar. Medal-winning performances show the possible and provide a model for future improvement. GPs are uniquely placed to spot the talent and report the score widely and rapidly.
Eyes on the prize: what’s the next goal?
If we can normalise the clinical handover to young GPs who are the future of general practice, it will encourage them to demand it of their hospitals.
Hospitals are incredible places, but the aim is for patients to return home to their communities and trusted GPs. They come home. Their GPs are waiting, willing and able. We can do better, and we will. We extend an open hand to our amazing hospitals. Pass us the baton – we won’t drop it.
Dr Katrina McLean is a Gold Coast-based GP, Assistant Professor in the School of Medicine and Health Sciences at Bond University, and a GPDU administrator.
Dr Michael Rice is past-president of the Rural Doctors Association of Queensland, an educator of students and registrars, a long term resident and rural GP in Beaudesert. He’s a keen user of social media.
Dr Nick Tellis is passionate about great general practice. He’s a proud GP, beachside Adelaide practice owner, and a happy new father. He blogs at www.partridgegp.com when not administrating on GPDU.
Contact Dr Nick Tellis at drnt@partridgegp.com.au or 0882953200 if You are a Great GP and want a Better Place to practice great medicine!
General Practice is the greatest vocation there is. Every day GPs are proud to use their skills and training to help their patients have better health and better lives. It’s incredibly rewarding for us and our patients (and the statistics!) show that it’s rewarding full stop.
Recently, Dr Tim Senior answered the question ‘Do we even need Doctors?‘. He concluded that GPs ‘know what to do when we don’t know what to do. And I can’t think of any other profession we can say that about’. So let’s have a look at a topic where GPs have to make hard decisions when we don’t know what we have to do.
Australia has an aging population and Australia is big. Really big! Driving and Australia go together like Vegemite and Toast! What do we do when aging drivers see their GP and we make a diagnosis of Mild Cognitive Impairment or Dementia?
Here is the excellent Dr Genevieve Yates with a very personal and professional view on the matter.
Here is another excellent video from Professor Joe Ibrahim.
In South Australia we have clear(er) guidelines on Fitness to Drive, with Mandatory Reporting and the associated safeguards for GPs who report patients they believe to be impaired. It’s still a hard decision. For example, just look at Kate Swaffer who has been diagnosed with dementia. What would you do?
What would I do? I’m not sure. Every patient is different and that’s one of the reasons why General Practice is, as I said above, the best vocation in the world. GPs will keep learning every day of their professional lives to serve their patients better. My advice to patients is to See Your GP, your best source of information, advice, and support for all of those hard decisions, when you don’t know what to do.
We’re Here to Help.
NEW: We can now refer for sub-specialist driving assessments!
PartridgeGP is here to help – and we will continue to serve our valued patients! PartridgeGP works with you to help you make your best health decisions, and we won’t back away from being your companion, guide, advisor, and sounding board through your health journey. We pride ourselves on great communication and we’re ready to share our professional skills and knowledge with you. This is only MORE important now, in the time of a global pandemic with a new vaccine on the horizon. The way forward is clear: make your appointment with us conveniently online right here – or call our friendly reception team on 82953200.
Where to from here?
For everyone, we believe that having a usual GP or General Practice is central to each person’s care and recommend that people with any health issues that come to the attention of other health professionals should be advised to attend their usual GP or General Practice rather than a specialised service (ie a place not providing the holistic care a specialist GP would). If they say that they don’t have a usual GP or general practice, they should be helped to find one and to actually attend it. Call PartridgeGP on 82953200 or make an appointment online here.
(Hat tip: Dr Oliver Frank)
(TL;DR – Get a regular GP or General Practice and use them!)
If you’re employed, get a side hustle and get into business. If you’ve already got a business, get a network. Want to get started? Find your tribe here!
If you are a great GP or a great Allied Health Professional, and you want to serve your clients or patients to the best of your ability, without worrying about all the non clinical things that get in your way, lets talk. Call Dr Nick Tellis on 8295 3200 and have a coffee and chat with us as to how PartridgeGP can help you to help others.
Just revisiting an old post after listening to a great podcast – ‘The Good GP‘. It got me thinking. We know that General Practice is a good thing and reduces hospitalization rates (and hence healthcare costs) – but how can we measure this in our own practices?
Professor Barbara Starfield’s work clearly demonstrates that countries with a strong GP-centred system have much better health outcomes than countries that don’t.
Maybe utilization of Advance Care Directives could be part of this?
Read on!
We have all wished for superpowers – I know I have! Flying, changing the past, and predicting the future would all be fantastic abilities to have. I can’t promise the ability to fly, nor can I give you last weeks winning Lotto numbers prior to last weeks draw. However, I can predict the future for you. At some point in the future, all of us will be unable to make decisions for ourselves. We may be unlucky enough to be in an accident, have a severe illness, or we may just be facing the final stages of a long life well lived, but the time will come. I was lucky enough to hear Dr Chris Moy speak eloquently on some changes to the law here in South Australia that will give all of us the power to have decisions made for us, according to our wishes, if we cannot express them at the time.
Why is this important?
This is why.
From SA Health:
From 1 July there will be a clear decision-making framework and new protections for health practitioners when they find themselves in the difficult position of trying to determine what someone in their care might want, at a time when their patient’s ability to make decisions is impaired.
The new Advance Care Directive Form replaces the existing Medical Power of Attorney, Anticipatory Direction and Enduring Power of Guardianship with a single Advance Care Directive Form (however any of these existing forms will continue to have legal effect post 1 July 2014).
The Advance Care Directive Form allows individuals to appoint substitute decision-makers and/or to clearly document their values, wishes and instructions with respect to their future health care, living arrangements and other personal matters.
And you can find some further information here:
Or you can complete it online here:
Use your new power wisely!
Remember, if you have any questions, ask Your GP!
UPDATE:
From David Coluccio of Senexus Aged Care Solutions!
Hi there,
http://www.linkedin.com/pulse/two-small-pieces-paper-guaranteed-save-your-family-time-coluccio
Kind regards, David
UPDATE 2:
What are the costs of aged care?
Read here and any questions? Partridge Street General Practice are Here.
UPDATE 3:
Some further reading on end of life care!
Most nursing home residents want CPR if their heart stops in the belief they’ll have a good outcome, a national survey reveals.
While survival rates after cardiac arrest are as low as 5% for older people receiving CPR, a survey of more than 2000 nursing home residents found 44% believed they had a good chance of recovering.
“This view is perhaps not surprising given that opinions about the likely outcomes from CPR are often informed by television medical dramas,” said researchers from Monash University.
The misplaced perceptions likely explained why 53% of residents expressed a desire to receive CPR in the event of cardiac arrest, they added.
“These findings highlight the need for older people to be better informed about cardiopulmonary resuscitation, including a clear understanding of what is involved … and a realistic perception of outcomes,” they suggested.
The researchers said the wide gap between expectations and reality also showed the need for novel approaches to end-of life planning in nursing homes.
A new ‘Goals of Care’ model had been developed to replace the old ‘Not For Resuscitation’ orders, they noted.
Under this system, the doctor could assign a patient to curative, palliative or terminal phases of care, based on an assessment of their likely treatment outcomes.
“This transfers the technical medical decision-making responsibility to a physician, who can work with the preferences of the patient or resident, but has an understanding of how likely it is for victim to achieve their previous health state,” the authors explained.
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