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OR4: Population health approach

OR4: Population health approach

In practice, a population health approach for a service provider has two dimensions:

  1. understanding the health outcomes of service populations (i.e. the populations from which clients are drawn); and
  2. understanding the health outcomes of groups of clients.

Implicit in a population health approach are:

Definition

Consideration of “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart 2003).

What to look for

Service populations

Groups of clients

Please read and discuss the short journal article synopses below. Your discussions should be guided by the following:

  1. Identify and briefly reflect on one feature of this OR that is clearly evident from this study. One example will be shown when you click 'show answer'.
  2. Identify one other feature of this OR that you think might be implied by the study.
Increasing PAP smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement+

Journal abstract

Reference: M. Dorrington, A. Herceg, K. Douglas, J. Tongs & M. Bookallil 2015, Increasing PAP smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement, Australian Journal of Primary Health, vol. 21, pp. 417–422.  

This article describes translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to PAP smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS). Rapid Plan-Do-Study-Act (PDSA) cycles were conducted, informed by client surveys, a data collection tool, focus groups and internal research. There was a statistically significant increase in PAP smear numbers during PDSA cycles, continuing at 10 months follow up. The use of TR with CQI appears to be an effective and acceptable way to affect PAP smear screening. Community and service collaboration should be at the core of research in Aboriginal and Torres Strait Islander health settings. This model is transferrable to other settings and other health issues.

PLAN

Topic: PAP smear screening

Issues: Australian Aboriginal and Torres Strait Islander women have lower PAP smear rates compared with other Australian women, with twice the incidence of cervical cancer and fivefold the mortality. Locally, our urban Aboriginal Community Controlled Health Service (ACCHS) had a screening rate of 42.3% at June 2012, according to Medicare Australia data, compared with a national average of 57%.

Approach: Rapid Plan-Do-Study-Act (PDSA) cycles of CQI were combined with translational research (TR) in this study. A multidisciplinary female staff focus group was established and used alongside a pre-existing client Women’s Group to plan interventions, including assessing practicality and cultural appropriateness. Stakeholders were engaged through focus groups to enable change.

Baseline data: Literature was reviewed to assess barriers and facilitators to PAP smear screening and interventions in local and international settings. Previous internal research from our ACCHS regarding PAP smear screening rates and staff opinions of client barriers to screening was assessed. In addition, a small survey was undertaken with a convenience sample of 32 clients in the clinic waiting room to assess preferences for PAP smear screening, personal barriers and facilitators to screening, and PAP smear history. The numbers of PAP smear results received between 1 January 2009 and 30 September 2013 were extracted from the service electronic medical records and fed back to focus groups.

DO – ACT (‘SMART PLAN’)

Improvement Strategies: Five rapid PDSA cycles were completed. All interventions were continued once commenced, with each cycle lasting 4–5 weeks. Act cycles involved: - implementation of a client survey administered during consultation; waiting room display of PAP smear promotional material and distribution to female clients of promotional make-up mirrors and nail files; establishment of an afternoon clinic specifically for women’s health appointments with a female GP; review and cleaning of the PAP smear recall system to make it more manageable; updating of the reminder letter to include specific information about cervical cancer in Aboriginal; and provision of education to the Social Health Team around prevention in women’s health, especially cervical cancer and screening.

STUDY

Study activities included: regular analysis and review of information from the client surveys (completed by 225 women); regular review of the interventions with ACCHS staff involved in implementation; and regular updates provided at medical staff meeting. The impact of the changes on PAP smear numbers was calculated by comparing record numbers of clients who were sent reminder letters with those who subsequently had PAP smears. There was a statistically significant increase in screening demonstrated through an increase in the average daily numbers of screens completed each month; and the overall screening rate - according to Medicare Australia data, the increase in PAP smears over the 30-month reference period was 8.4% (from 42.3% at 30 June 2012 to 50.7% at 30 June 2013).

Reflections

while each community has specific health priorities and barriers and facilitators to accessing health care, each service also has its own limitations. Barriers to Pap smears identified by our clients have been identified in previous research - our service consultation allowed prioritisation of local barriers and facilitators, and identification of what could be affected by internal changes. The benefit of specific community consultation became evident as previous staff consultation within our ACCHS recommended having an external health professional run a clinic for Pap smears. While there was a perception among staff that knowing the person performing a Pap smear would be a barrier for clients, this was not demonstrated in our client survey.

The most common reason clients reported for having PAP smear screening was GP prompting. Reminding about PAP smears during a consultation and having appointments available were two simple, yet effective changes demonstrated by our research. This was particularly apparent with the uptake of smears by women who had never had a smear before or were under-screened.

Use of rapid PDSA cycles was intensive. For sustainable time and commitment from health service staff, ongoing CQI requires less intensity over longer periods. Our model otherwise mimicked regular health service CQI with all those involved (including the researchers) being members of staff.

For discussion

Please read and discuss the journal article synopsis/es below in order to:

  1. Identify and briefly reflect on one feature of this OR that is clearly evident from this study. One example will be shown when you click 'show answer'.
  2. Identify one other feature of this OR that you think might be implied by the study.

SHOW ANSWER

Hospital to home: An integrated approach to discharge planning in a rural South Australian town+

Journal abstract

Reference: D. Bolch, J. B. Johnston, Lynne C. Giles, Cr. Whitehead, P. Phillips & M. Crotty 2005, Hospital to home: An integrated approach to discharge planning in a rural South Australian town, Australian Journal of Rural Health, vo. 13, pp. 91–96.

Objective: To produce safer and more integrated hospital discharge planning practices for older people living in rural and remote settings.

Goals (Aims): (i) implement a system of discharge planning appropriate for a rural and remote setting; (ii) meet the needs of older patients and their carers for safe, timely and effective discharge; and (iii) improve continuity of care across the hospital–community interface.

Design: Plan–Do–Study–Act framework using case note audit and focus groups.

Setting: Central Yorke Peninsula Hospital in South Australia.

Intervention: Range of communication strategies designed to improve discharge planning practices. Many cycles of PDSA occurred as the interventions were developed, monitored and subsequently refined.

Main outcome measures: Percentage of patients with documented discharge plan, Percentage of patients risk screened, Percentage of community health service provider referrals, Percentage of patients followed up within 10 days of discharge (data disaggregated Aboriginal vs non-Aboriginal).

PLAN

Topic: Hospital discharge planning for older people

Issues: A total of 46% of non-Aboriginal patients and 7% of Aboriginal patients had a documented discharge plan at baseline, and risks were identified on the nursing care plan for 17% of non-Aboriginal patients and none of the Aboriginal patients. No timely follow up of any patients by hospital staff following discharge was evident from the case-note audit. Referrals to community health services were also poor, with only 27% of non-Aboriginal clients and 14% of Aboriginal clients referred to allied health services within 48 h. It was not possible to determine if patients were referred in a timely manner.

Approach: The PDSA cycles allowed extensive consultations with the following stakeholders: consumers, hospital staff and community service providers. GP involvement was important as GPs managed patient care in both the hospital and community settings. Extensive internal and external stakeholder consultation occurred through focus groups with staff, Aboriginal and non-Aboriginal consumers, project team and steering committee forums and informal communication. Consultation also incorporated stakeholder surveys and interviews.

Baseline data: Data collected at baseline included: A retrospective audit of patient case notes (n=104) for October 2001 to March 2002; separate focus groups for staff, Aboriginal, and non-Aboriginal consumers; [RO5] and semi-structured interviews with community health workers; questionnaires for local GPs. Qualitative data showed a high level of confusion amongst consumers about available community services following discharge and how these services could be accessed. Interviewed community health service providers (n=9) all raised issues about patient referrals, including low numbers of referrals, untimely referrals and poor documentation within referral forms. GP surveys (n=7) indicated that discharge planning was fair, with five respondents stating that patients could be discharged earlier if home services were.

DO – ACT (‘SMART PLAN’)

Improvement Strategies: A new discharge planning framework was established. This included a redesign of the patient admission form to incorporate a risk assessment tool, and the development of case-note ‘flags’ to identify existing services provided. Referral processes to community-based services were streamlined and widely communicated. Central to the interventions was the notion that all members of the clinical team should take responsibility for discharge planning. Most initiatives combined practice and communication improvements, and dissemination of information was of key importance in decreasing confusion amongst stakeholders. Flip charts and information transfer packs, designed for use in the hospital environment, were adopted enthusiastically by community health care providers. Post-discharge communication was initiated, with a telephone call to all patients aged at least 65 years, and Aboriginal patients at least 45 years, within 10 days of discharge. Many of these interventions were simple, user-friendly tools designed to streamline internal and external communication processes. Baseline data showed discharge planning was poorer for Aboriginal patients than non-Aboriginal patients. One staff focus group member stated, ‘I want to find out risk factors and care for them [Aboriginal clients] but am often met with aggression.’ These issues required careful handling by the project team. Cultural awareness training was provided for staff, with the course designed to foster respect for cultural diversity. The employment of an Aboriginal liaison officer also contributed to progress in this area. Staff and non-Aboriginal focus groups also provided a forum for promoting cultural awareness.

STUDY

Throughout the Study phase, monthly focus groups were held, and used to regularly monitor interventions in an open forum. These discussions were integral to the Act stage of the PDSA cycle. Based on the review of KPIs, some new interventions were generated during the project and existing interventions were refined.
The study phase of the project incorporated ongoing monitoring of four KPIs, namely:

  1. Commencement of the discharge plan
  2. Provision of timely and informative risk screening
  3. Timely notification of community providers
  4. Follow up of the discharge plan.

The importance of ongoing education was identified 4 months into the project when performance began to fall on several indicators. Prompt action by the project team resulted in subsequent improvement in most KPIs by the end of the project. Evaluation of interventions by the staff focus group in the Study phase resulted in multiple amendments to the nursing admission and risk-screening tool based on users’ experience in applying the tool in the clinical setting. The ongoing evaluation of the project also resulted in several new initiatives from the Aboriginal focus group, and these included raising of the Aboriginal flag outside CYPH. The non-Aboriginal focus group identified the need for an information pack for patients being discharged from hospital.

These KPIs were measured by case-note audit on a monthly basis and reviewed by the project team, focus groups, steering committee and lead site hospital. An initial improvement in all indicators was followed by reduced performance in early 2003, which led to intervention refinement (the Act phase).

Reflections

The project was important and newsworthy in the local community. Establishing focus groups created a way for all stakeholders to contribute actively in the development of health services at CYPH. Their energy and interest were harnessed to support development, communication and sustainability of interventions. [champions]

The high level of involvement of the Aboriginal community through the focus group was also integral to the success of the project. One participant stated, ‘Previously Aboriginals did not feel comfortable in the hospital and did not feel that they were welcome, now we feel as if it is our hospital too’. Feedback from the Aboriginal community was very positive, with two sentinel comments being ‘I never thought I would see it [raising of the Aboriginal flag] in my life time’ and ‘It brings tears to my eyes to see it [the Aboriginal flag] flying.’ This [Aboriginal] consumer focus group is ongoing and provides both a sustained mechanism for consumer involvement and promotes strengthened relationships between the local Aboriginal community and the health services.

Some challenges were experienced in working within this rural and remote site. The high level of interest and ownership of the project meant that everyone wanted to ‘have their say’ and this often slowed down development of interventions. For example, the nursing assessment/risk assessment tool was modified 12 times following implementation as a result of staff feedback. Difficulties with access to information technology, administrative support, and competing workloads for the project officers were also limitations. Information technology was poorly supported with internet connections difficult to establish and maintain. The administrative infrastructure for the development of forms, questionnaires, tools and resources was not available on-site. A further challenge experienced by the project team was an ongoing requirement for the project officers to work additional shifts in the clinical setting due to nursing staff shortages.

For discussion

Please read and discuss the journal article synopsis/es below in order to:

  1. Identify and briefly reflect on one feature of this OR that is clearly evident from this study. One example will be shown when you click 'show answer'.
  2. Identify one other feature of this OR that you think might be implied by the study.

SHOW ANSWER