Getting better faster Ambulatory Care Newsletter Volume 6 Spring Edition 2008 Inside this issue Remote monitorin

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					Getting better faster
Ambulatory Care Newsletter                                                              Volume 6/Spring Edition 2008

Inside this issue:                     Remote monitoring to help Western
Message from the editor           2    Australians better manage heart failure
FOODcents                         2
                                       Western Australian researchers are           intake and weight, combined with
Cooking with Deadly Tucker        3    aiming to help people with chronic heart     taking prescribed medications.
Stay On Your Feet® Week 2008      4    failure (CHF) avoid trips to hospital by     “Unfortunately, self-monitoring is often
                                       better monitoring their condition.           not effectively undertaken by patients
Don’t fall … FLIP!                5
                                       Patients are currently being recruited to    in the community setting,” he said.
Physiotherapy reducing falls      6    a study that will assess the effectiveness   “Using the home monitoring system
Pulmonary rehabilitation               of using a remote monitoring system as       should help patients identify early
helping Western Australians            part of CHF management.                      signs of increasing heart failure,
stay out of hospital              7    Patients in the study will be allocated      making it possible for them to work
Which patients get the                 to one of two groups. Group one will         with their GP and cardiologist to get
greatest benefit from chronic          continue their usual care, while group       early treatment in the community –
disease programs?                 8    two will be provided with a home             therefore avoiding a trip to hospital.”
Osborne Park Hospital getting          monitoring system that measures              Patients with severe CHF experience
older people home faster          9    blood pressure, heart rate, heart            repeated episodes of heart failure,
                                       rhythms, lung volumes, oxygen levels         requiring frequent trips to hospital
Chronic disease teams assisting        and weight. Patients will undertake
people to improve their health    10                                                emergency departments and often
                                       daily monitoring using the user-friendly     long stays in hospital.1 Hospital
Chronic disease teams on               system. The information collected            admissions related to CHF are costly
the move                          10   will be automatically downloaded to a        to both patients and our health
Would you follow a diabetes            central monitoring station and reviewed      system. In 2005/06 admissions to Sir
treatment plan?                   11   by a heart failure nurse.                    Charles Gairdner Hospital cost almost
Home oxygen therapy reducing           According to principal investigator          $6 million.2
hospital stays for kids           12   Professor Peter Thompson, current            A total of 102 patients across Western
                                       management of CHF stresses the               Australia will be examined in the study,
                                                                                    which runs for 12 months. Funding
                                                                                    from WA Health’s State Health Research
                                                                                    Advisory Council has enabled the study
                                                                                    to expand from a metropolitan study to
                                                                                    a state-wide project.
                                                                                    For further information about
                                                                                    the project, please contact:
                                                                                    Kim Gibson, Project Coordinator
                                                                                    North Metropolitan Area Health Service
                                                                                    ph (08) 9346 2282 or
                                        Nurses Maria Sheehan (left) and Eve Allen,
                                        with trial participant Stanley Lebeck      References:
Contact details:                       importance of patient self-
                                                                                    1. Krum, H. et al., 2006. Guidelines for the
                                                                                      prevention, detection and management of people
Editor: Jennie Caldwell                management. This self-management               with chronic heart failure in Australia. Medical
Tel: 0424 505 503 or email:            involves regular self-monitoring of            Journal of Australia, 185 (10), pp.549-556.     blood pressure, heart rate, fluid
                                                                                    2. SCGH Business Unit, June 2008. HMDS extract.
  Getting better faster

  Message from the editor
  When the previous edition of Getting Better Faster was          A great example of avoidance care is shown in the story on
  released in July, several people asked me: “What is             page 7, in which people with lung disease are reducing their
  ambulatory care?” Ambulatory care is healthcare provided        trips to hospital through physiotherapy classes.
  in the community to help people manage their health,            Substitution provides community-based care as an
  maintain their independence and stay out of hospital.           alternative to treatment traditionally provided in hospital.
  Care may be provided in a range of settings, for example        Princess Margaret Hospital’s new substitution service is
  at home, a community centre or a clinic.                        showcased on page 12. The service enables children with
  Ambulatory care services may be described as avoidance          bronchiolitis to receive oxygen therapy at home.
  or substitution.                                                If you have any further questions about ambulatory care,
  Avoidance care aims to help people better manage their          please ask. The more you know about this service, the
  health and keep well – preventing the need to go to hospital.   more benefit you and your patients can gain from it.

  FOODcents - Supporting people to make healthy diet and
  lifestyle choices
  By Barbara Hollin, Australian Red Cross WA

  The Red Cross FOODcents Program provides assistance to          Red Cross works with different community groups that
  individuals and families who want to make significant diet      include the Indigenous and refugees, as well as those at
  and lifestyle changes. Trained Red Cross staff and volunteers   risk of or diagnosed with chronic disease. The Red Cross
  offer guidance on ways to achieve a healthy lifestyle, save     FOODcents Program supports people to make and sustain
  money on food shopping, and teach participants how to           major changes to their lifestyle choices.
  prepare and cook healthy, affordable, tasty meals.              For more information about the Australian Red Cross
  In 2004, Australian Red Cross WA family services staff          FOODcents Program or to make a referral, please call
  who worked with socially isolated new mothers                   Barbara Hollin at Red Cross on (08) 9225 1984 or email
  identified poor nutrition, budgeting and cooking skills
  as key recurring issues in the family home. Red Cross
  developed the FOODcents program, incorporating the
  WA Health Department’s FOODcents tools, for delivery
  in participants’ homes. The program proved very successful
  and attracted funding to enable strategies to be trialed
  with a variety of client groups and in a range of locations.
  In May 2007, the Red Cross FOODcents Program
  received a major funding boost from the WA Health
  Department to expand considerably in geographical area
  and scope. The program now includes activities that
  address healthy weight, physical activity, injury and burns
  in children, as well as healthy diet and effective shopping
  and budgeting skills.
  The program has grown and developed from discreet one-
  on-one sessions in the family home to include fun,
  interactive group sessions held in a wide variety of
  community venues.
  The group sessions involve six to twelve people
  and provide the opportunity for vulnerable participants to
  support each other to make and sustain healthy lifestyle
  choices for themselves and their families.                      Members of the Belmont Red Cross FOODcents Program. Photo:
                                                                  Australian Red Cross/Tim Lofthouse

2 Spring Edition 2008
Getting better faster

Cooking with Deadly Tucker
The Deadly Tucker Cookbook is a collection of healthy, low
                                                                                    A selection of recipes from the FOODcents for
cost and easy to prepare recipes, developed specifically                      Aboriginal and Torres Strait Islander People in WA Program.

to meet the needs of Aboriginal and Torres Strait Islander
people in Western Australia. The term “deadly” means
very good, tops or cool.
The cookbook takes into consideration the diverse nature of
Aboriginal and Torres Strait Islander communities. As diabetes
is an issue within the Aboriginal and Torres Strait Islander
population, the cookbook reinforces the concept of why
some foods are not appropriate for people with diabetes.
Kerry Smith, a nutritionist with the Health Promotion Team
at Nindilingarri Cultural Health Service, said it was wonderful
that the cookbook was simply set out with illustrations for
each step, including the ingredients required.
“The recipes are appealing with their colour photos and
use of locally available ingredients,” she said.
“They are very useful for reinforcing the concept of
including vegetables in every meat meal. Overall the
Deadly Tucker Cookbook is a highly valuable and practical         Organisations using the book include Aboriginal hostels,
resource for aboriginal communities.”                             universities, general practice divisions, prisons and
The Deadly Tucker Cookbook is intended to be used as              community organisations. Over 2,500 copies of the
part of the FOODcents for Aboriginal and Torres Strait            cookbook have been distributed.
Islander Program, but can also be used as a stand alone           According to Jennifer White, Project Manager with the
resource. The program, adapted from the Department                North Metropolitan Area Health Service Public Health Unit,
of Health’s FOODcents Program, includes budgeting,                health professionals can use the Deadly Tucker Cookbook as
cooking, a supermarket tour and suggests changes to the           a starting point when addressing health issues.
way people spend money on food.                                   “Discussion and exploration of issues may evolve as
                                                                  communities work with the cookbook,” she said.
                                                                  Due to its versatility the cookbook could be used in a
                                                                  number of contexts, including at schools and camps, by
                                                                  communities and families, and with men. Kerry Smith has
                                                                  found the cookbook particularly useful for women who
                                                                  prepare meals for schoolchildren and older people. She
                                                                  has also provided copies of the book to school teachers
                                                                  who are teaching nutrition and food preparation, store
                                                                  owners who supply ingredients for whole communities,
                                                                  and some takeaway food stores.
                                                                  Both Kerry Smith and Tracy Leon, Senior Dietician
                                                                  Kimberley Division of General Practice, get a lot of
                                                                  positive feedback when using the book in the Kimberley
                                                                  region. It has been well received by community members,
Deadly Tucker Class participants with Janice Reidy from           including Aboriginal mums with young children, Aboriginal
Diabetes Australia (middle).                                      men, allied health workers and local nursing staff.
                                                                  If you would like to order a copy of the Deadly Tucker
The Red Cross is funded to provide the FOODcents
                                                                  Cookbook, or would like further information, please contact:
program to clients. Where appropriate, the
organisation presents the Aboriginal and Torres Strait            Vilma Palacios, Health Promotion Coordinator
Islander adaptation of the program. The Red Cross offers          Public Health Unit, North Metropolitan Area Health Service
group sessions and individual sessions in the home.               ph (08) 9224 1606 or

  Getting better faster

  Stay On Your Feet® Week 2008
  Stay On Your Feet® (SOYF®) Week is an annual event
  that aims to reduce the incidence of falls in seniors and
  promote healthy ageing in Western Australia.
  Falls are one of the most common and serious problems
  faced by people aged 60 years and over, with one in
  four Western Australian seniors falling annually. Of
  these, one third requires medical treatment1. Most falls
  are preventable.
  A large number of seniors took part in SOYF® Week 2008,
  participating in activities and events across the state.
  More than 250 organisations and seniors clubs were
  involved, running falls prevention activities such as Tai
  Chi demonstrations and guided walks through Kings Park.
  The week ran from September 14-20.
  One of the week’s key messages was to encourage seniors
  to report falls, fears of falling and balance problems to a
  health professional.
  According to Suzanne Ralston, Manager of Falls Prevention
  at the Injury Control Council of Western Australia (ICCWA),
  encouraging seniors to report falls to health professionals
  and asking their falls history where possible, assists
  appropriate falls risk assessments and management.
  “Often falls are caused by one or a combination of risk
                                                                Lorraine and Ken Paynter - members of the Garden City
  factors which, once known, can be managed to facilitate
                                                                Shopping Centre Walking Group
  healthy, active ageing and independence,” she said.
  SOYFWA® volunteer Nancy Ciampini said that after              “I had my eyes tested, medications checked and worked
  learning the main reasons why people over 65 years fall,      on building my balance and strength through appropriate
  she saw her GP to work out the areas she needed to            exercise. Now I talk to other seniors about the steps they
  concentrate on.                                               can take to stay independent,” she said.
                                                                SOYF® Week was coordinated by ICCWA and funded by WA
                                                                Health. WA Health provided organisations with grants of
                                                                $500 or $1000, assisting them to hold a range of events.
                                                                ICCWA is dedicated to developing and implementing
                                                                educational and awareness raising programs, such as the
                                                                SOYFWA® program, to reduce the number and severity
                                                                of falls among seniors. ICCWA is also committed to
                                                                promoting falls reporting and referral systems.
                                                                The Stay On Your Feet WA® Resource and Information
                                                                Centre has been established by ICCWA and funded by WA
                                                                Health. The resource and information centre provides
                                                                a ‘one-stop-shop’ for falls prevention information and
                                                                resources for health professionals and seniors.
                                                                For more information, call the SOYFWA® Resource
                                                                and Information Centre on (08) 9420 7212 or visit
                                                                1. Evaluation report prepared for the Injury Prevention Branch,
                                                                    Department of Health, 2006. Stay on your feet WA program evaluation
  Wushu group demonstrating Tai Chi at the SOYF Week launch        report: Falls outcome analysis.

4 Spring Edition 2008
Getting better faster

Don’t fall … FLIP!
By Susannah Wallman
Project Manager, Falls Linkage Independence Program
North Metropolitan Area Health Service

Almost 75,000 Western Australians over 60 years of age           The WA Falls Prevention Health Network has led the
fall each year. Of those who do fall, one in three need          planning and development of this project. Ongoing
medical attention and eight per cent are admitted to             collaboration between the Falls Prevention Health
hospital1. With an increasing elderly population and             Network, ABHI, Ambulatory Care, CPS and the
projected increases in health system costs attributed to         Perth Primary Care Network has been critical in the
falls2, there is a strong need to address this issue.            implementation of this service.
The Falls Linkage Independence Program (FLIP) is a new           For more information about the program, or to refer
project that aims to reduce the incidence of falls and falls-    a client to FLIP, please contact the project team on
related injuries. The program provides a community-based         0420 279 515 or
service for older people at risk of falling.                     For further information about the Falls Prevention Health
The service is delivered by two Community Falls Specialists      Network please visit:
and a Therapy Assistant. Each client is assessed to identify
the factors that put them at risk of a fall. If clients
have problems with their strength, balance or walking,
                                                                 1. Evaluation report prepared for the Injury Prevention Branch,
they may receive a targeted exercise intervention. This
                                                                     Department of Health, 2006. Stay on your feet WA program evaluation
can include an individual home-based exercise program,
                                                                     report: Falls outcome analysis.
referral to a Community Physiotherapy Services (CPS) falls-
                                                                 2. Hendrie, D. et al., 2004. Health system costs of falls of older adults in
specific group exercise program or a recommendation to
                                                                    Western Australia. Australian Health Review,
attend an exercise program in their local community.
                                                                    28(3), pp.363-373.
The individual and CPS exercise programs are based on the        3. Otago Falls Prevention Program designed by the Falls
well established and evidence-based Otago Falls Prevention          Prevention Research Group, University of Otago Medical School,
Program3. In addition to the exercise component, clients             New Zealand.
may be referred to appropriate community providers for
interventions relating to other falls risk factors identified.
Clients may be referred to FLIP by
their GP or a hospital or community
health professional. Clients can also
self-refer or be referred by a family
member or carer.
Initially the service is being piloted
across sixteen postcodes in the Perth
metropolitan area: 6000, 6003-6006,
6050-6058, 6062 and 6063. It is
anticipated that the pilot evaluation
will demonstrate the need for an
ongoing service, with expansion to
other areas in Western Australia.
The project is run by WA Health
and funded through the Australian
Better Health Initiative (ABHI) - a
joint Australian, State and Territory
Government initiative that aims to
refocus the health system to promote
good health and reduce the burden
of chronic disease.

                                            Physiotherapist Alison Hamersley with Judith Schotte

  Getting better faster

  Physiotherapy reducing falls in the community
  By Alison Hamersley
  Senior Physiotherapist, Community Physiotherapy Services
  North Metropolitan Area Health Service

  One in four people aged 60 years and over fall each year.       To refer clients to CPS telephone (08) 9224 1783, or
  By 2021, it is predicted that almost 40,000 people will         visit the website at
  attend WA emergency departments each year because of a
  fall, with an associated health system cost of $174 million1.
                                                                  1. Evaluation report prepared for the Injury Prevention Branch,
  Community Physiotherapy Services (CPS) runs land- and               Department of Health, 2006. Stay on your feet WA program
  water-based classes each week for clients at risk of having a       evaluation report: Falls outcome analysis.
  fall. These classes aim to maximise the client’s independence   2. Otago Falls Prevention Program designed by the Falls Prevention
  and promote healthier ageing. The class content includes           Research Group, University of Otago Medical School, New Zealand.
  physical activity, education and self-management.
  The programs emphasise balance, flexibility, strength,
  posture and functional ability. They also include health
  education and advice on relevant issues such as falls risk
  reduction, posture, back care, continence and home
  exercise programs.
  Since July 2007, CPS has provided falls prevention classes
  based on the No Falls program. This ten-week program,
  developed by Melbourne physiotherapist Susan Vincent,
  includes balance activities and exercises to improve
  leg strength. Each class has a maximum of fifteen
  participants. At the end of ten weeks clients are given a
  home exercise program.
  In 2007, 99 clients completed the program. Seventy per
  cent of clients showed an improvement in their balance
  by the end of the program.
  At the beginning of this year CPS started a class based
  on the Otago Program2, a well established and evidence-
  based program. This ten-week program caters for up to
  six participants and allows for more individual assessment
  and prescription of exercises. Education on factors related
  to falls prevention is provided, including environmental
  issues, home medicine review, footwear and eyesight.
  Six clients are currently attending this class and two have
  completed the program. Participant Mrs Irene Cooper
  commented that she found the program very helpful
  in encouraging her to exercise, and she is now walking
  every day with increased confidence. By the end of the
  program, Mrs Cooper’s balance had improved significantly,
  and is now above average for her age.
   The Falls Linkage Independence Program (FLIP) started
  in October this year (see the article on page 5). The
  program will provide a community-based service for older
  people at risk of falling. The aim is to reduce gaps in
  existing services, improve communication and facilitate
  linkages between health professionals.
  CPS is working collaboratively with FLIP and the Perth
  Primary Care Network to deliver the program.                    Physiotherapist Denise Berry with Irene Cooper

6 Spring Edition 2008
Getting better faster

Pulmonary rehabilitation helping Western Australians
stay out of hospital
                                                                               and health-related quality of life.
                                                                               “However, to our knowledge this is the
                                                                               first reported study of outcomes and
                                                                               hospitalisation data following pulmonary
                                                                               rehabilitation in Australian COPD
                                                                               patients over an extended period of
                                                                               time,” she said.
                                                                               The pulmonary rehabilitation program
                                                                               is run by the SCGH Physiotherapy
                                                                               Department. Each class of six
                                                                               to 10 patients is supervised by a
                                                                               physiotherapist, and sessions include
                                                                               exercise and education. The exercise
                                                                               component includes a 20 minute walking
                                                                               program, flexibility and stretching
                                                                               exercises, and an exercise circuit in a
                                                                               gymnasium. Informal education sessions
                                                                               which take place during the rest period
                                                                               encourage problem-solving and positive
                                                                               self-management behaviours.
                                                                                Participants are given information
Kaye White participating in the SCGH pulmonary rehabilitation program           on local patient support groups and
                                                             offered formal education on lung conditions and their
Researchers at Sir Charles Gairdner Hospital (SCGH) have     management. Where necessary, patients are referred for
shown that pulmonary rehabilitation helps people with        nutritional advice or smoking cessation counselling.
chronic obstructive pulmonary disease (COPD) to stay out
                                                             At the end of the eight-week program, patients are
of hospital.
                                                             encouraged to join a community-based maintenance
Principal researcher Nola Cecins, Dr Elizabeth Geelhoed      exercise class supervised by a physiotherapist and to
and Associate Professor Sue Jenkins found a 46 per cent      continue with their home exercise program.
decrease in the number of patients admitted to hospital
                                                             Nola Cecins and Sue Jenkins have been responsible for
with a COPD exacerbation, and a 62 per cent decrease in
                                                             running the program at SCGH since 1997. They also
total bed-days following pulmonary rehabilitation.
                                                             undertake research, teach entry level physiotherapy
Over a six-year period, the reduction in hospital            students at Curtin University of Technology and provide
admissions and length of stay resulted in a saving of        workshops for physiotherapists who run pulmonary
almost $400,000, while the program only cost around          rehabilitation programs. These workshops have been
$90,000. The net saving of more than $300,000 far            provided through the SCGH Physiotherapy Department
outweighed the cost of providing the program and             and Curtin University of Technology and held within WA,
enabled the health service to treat additional patients.     elsewhere in Australia and overseas in New Zealand,
Patients who completed the eight-week program also had       Singapore, Hong Kong, Thailand and Malaysia.
an improvement in exercise capacity and health-related       The study “Reduction in hospitalisation following
quality of life.                                             pulmonary rehabilitation in patients with COPD” was
The researchers reviewed data on 256 patients who            published in the August edition of the Australian Health
started the pulmonary rehabilitation program between         Review journal (
1998 and 2003. They compared hospital admissions in the      For more information please contact:
12 months pre- and post pulmonary rehabilitation.
                                                             Nola Cecins, Senior Physiotherapist
Nola Cecins said pulmonary rehabilitation is an effective    Sir Charles Gairdner Hospital ph (08) 9346 4408 or
management strategy for patients with COPD and has been
shown to reduce symptoms and increase exercise capacity

  Getting better faster

  Which patients get the greatest benefit from chronic
  disease programs?
  Associate Professor Alistair Vickery and
  his team are establishing a cutting-edge
  measure of the impact of a chronic disease
  management program (CDMP) in the north
  metropolitan area. The 12-month project
  will evaluate the impact of the CDMP on
  patient outcomes and hospital use. The
  project aims to identify which patients most
  benefit from participation in the CDMP .
  Chronic disease accounts for around 70 per
  cent of the total burden of disease and
  injury, and two-thirds of Australia’s health
  care budget1. As a result, programs that
  help these clients better manage their
  health, maintain their independence and
  stay out of hospital are critical.
  According to A/Professor Vickery, it costs
  Western Australian hospital services
  about $17,000 per patient for diabetes
  complications such as heart attacks, heart
  failure and stroke. As well as healthier
  patients with better control of their disease,
  an effective CDMP program provides
  significant financial benefits to our health
                                                 Diabetes education and exercise class Midland
  services and reduces hospital demand.
  The CDMP being examined is part of                            The team’s chief investigators are Professor Jon Emery
  Ambulatory Care in the North Metropolitan Area                (University of Western Australia) and Dr David Whyatt
  Health Service. The program provides free community-          (University of Western Australia and North Metropolitan
  based services to improve the health, well-being and          Area Health Service). Associate investigators Dr Joey Kaye
  independence of people with diabetes, chronic obstructive     (Sir Charles Gairdner Hospital) and A/Professor Peter
  pulmonary disease (COPD) and chronic heart failure. The       Kendall (Fremantle Hospital) will provide clinical expertise
  program emphasises patient education, self-management         on diabetes and COPD respectively. Associate investigator
  and collaborative care. The project will review the           Dr Grace Frances (Curtin University) will analyse the social
  diabetes and COPD programs.                                   determinants of health and Professor Nick Santamaria
  The project will collect a range of information, including    (Curtin University and Royal Perth Hospital) will analyse the
  biometric, hospitalisation and socioeconomic data.            cost effectiveness of the program.
  Factors such as duration and severity of disease will be      WA Health’s State Health Research Advisory Council is
  analysed to assess their influence on patient outcomes.       funding the project. The project team will work closely
  A preliminary evaluation investigated the impacts of the      with the Respiratory and Endocrine Health Networks.
  CDMP on a sample of patients referred to the program          For more information about the project please contact:
  during 2006 and 2007. A clinically significant improvement    Dr David Whyatt, Chief Project Investigator
  in functional capacity was demonstrated in the 46 COPD        Ambulatory Care, North Metropolitan Area Health Service
  patients reviewed. This level of functional capacity
  improvement has been associated with a 90 per cent            References:
  decrease in hospital days over 12 months2. The 10-year        1. National Public Health Partnership, 2006. Blueprint for nation-wide
  coronary heart disease risk decreased from 22 to 20 per           surveillance of chronic disease and associated determinants. Melbourne.
  cent in the 22 diabetes patients assessed. The 10-year        2. Stevens, et al., 2001. Clinical Science, 101, pp.671-679.
  fatal coronary heart disease risk decreased from 17 to 15
  per cent in this patient group.

8 Spring Edition 2008
Getting better faster

Osborne Park Hospital getting older people home faster
By Alison O’Toole
Senior Physiotherapist
Rehabilitation Aged Care Intervention Liaison Service

The Rehabilitation Aged Care Intervention Liaison Service         Referring GPs play an important role in supporting the
(RAILS) team is helping people aged 65 years and over             community aspect of RAILS by identifying at-risk clients
avoid trips to hospital and decrease their length of stay in      and referring them to the service. The Osborne Division of
hospital. The service is available to people in the Osborne       General Practice helps to maintain a high level of service
Park Hospital (OPH) Aged Care Assessment Team (ACAT)              use by providing ongoing program publicity to its GPs.
catchment area.                                                   The RAILS team started in 2005. In 2007 RAILS won
The multidisciplinary team, which consists of a clinical nurse,   an award in the Healthy Hospitals category at the WA
social worker, occupational therapist and physiotherapist,        Health Awards. RAILS continues to provide a successful
provides a range of hospital and community-based services         service, saving 356 inpatient bed days and preventing 62
and supports existing OPH programs.                               emergency department admissions in 2007/08.
Team members work closely with hospital staff to identify         “Pathways Home” funding from the federal government
patients who can be discharged early and to spot issues           has enabled RAILS to buy a new transport van and other
that may contribute to an extended length of stay.                additional resources. The team now has on hand the
Following early discharge, or when hospital admission             equipment needed for home assessments and rehabilitation.
is not required, the team can provide the following               For more information or to access the RAILS service
community-based services:                                         call (08) 9346 8315 between 8.00am and 4.30pm, Monday
   Assessment and treatment in the home - including               to Saturday.
   rehabilitation and urgent ACAT assessment.
                                                                  Patients, families and carers require a referral from their
   Organisation of in-home services and respite care.             GP to access the service.
   Education to carers and families on strategies to
   maintain the patient’s mobility and how to assist the
   patient to move.
   Specialist walking aid provision.
   Referral to day hospital for review by geriatrician or
   allied health.
   Nursing assessment and community follow-up.
RAILS also receives urgent community referrals from GPs,
Joondalup Hospital Campus Older Persons Initiative and
Sir Charles Gairdner Hospital Emergency Department.
Following a preliminary medical assessment by the RAILS
nurse an admission can be made under the direction of
the patient’s OPH consultant and GP, potentially avoiding
an admission via the emergency department.
The RAILS team’s ability to rapidly respond to clients in
the community helps people to continue living in their
own homes, through the provision of comprehensive
assessment, planning and access to resources.
This successful community component of RAILS
differentiates it from other hospital-based discharge support
programs, which have primarily focussed on reducing
hospital length of stay and providing rehabilitation or
support to patients after discharge from hospital.
RAILS refers clients to other community support services
if ongoing management is required, as the team’s                  The RAILS team - Carolyn Moody (Clinical Nurse), Deanne
intervention is short-term to assist with urgent clinical,        Jones (Senior Occupational Therapist), Alison O’Toole (Senior
functional and social issues.                                     Physiotherapist) and Jo Menzies (Senior Social Worker)

   Getting better faster

   Chronic disease teams assisting people to improve their
   health and well-being
   By Laura Stuchbury
   CDMT, South Metropolitan Area Health Service

   People with chronic diseases can improve their health and      The CDMTs aim to help clients by:
   well-being – but may need help to learn why and how.              increasing knowledge of their condition
   Western Australia’s Chronic Disease Management Teams              helping address barriers to making lifestyle changes
   (CDMTs) provide a free community-based service that
                                                                     helping take control of symptoms by monitoring them
   helps people with diabetes, heart failure and chronic
                                                                     and responding appropriately
   obstructive pulmonary disease (COPD) stay in control of
   their health and avoid unnecessary trips to hospital.             encouraging clients to actively share in decision-
                                                                     making with health professionals
   The following story shows how CDMT dieticians in the
   South Metropolitan Area Health Service are changing               managing the physical, social and emotional impact of
   people’s lives…                                                   the condition on their lives

   Mrs D is an 81-year-old woman with COPD. When first               living a healthy lifestyle.
   referred to the CDMT her main concern was that she had         For further information about the CDMTs call 1300 855 841.
   lost weight. The dietician helped Mrs D identify a range
   of physical and social reasons for this loss, including
   difficulty chewing foods and disliking eating alone. As well
   as frequent skipping of meals and snacks, Mrs D’s diet was
   high in saturated fat and low in fibre.
   The dietician worked with Mrs D to help her understand
   the principles of healthy eating. The dietician and Mrs
   D then negotiated easy, affordable and realistic goals
   to change her eating habits. The common agreement
   of goals was important as the dietician needed to
   understand what was realistic for her client, as clients
   are less likely to achieve goals imposed on them.
   At her follow-up visit, Mrs D reported that she was
   enjoying regular nourishing meals and had gained three
   kilograms. Mrs D can now move on to her other care
   plan goals, including seeing other health professionals
   from CDMT and being linked to community and specialist
                                                                  The Fremantle Chronic Disease Management Team.
   services in consultation with her GP.

   Chronic disease teams on the move
   Chronic Disease Management Teams (CDMTs) in the                In July 2008 the north metropolitan CDMTs moved into
   metropolitan area have recently moved. The new                 Helena Street, Midland and Davidson Terrace, Joondalup.
   facilities enable them to offer a better service to            The new locations are closer to public transport, which
   their clients.                                                 means easier access for clients. The centres have
   The south metropolitan CDMTs are now located in Mills          dedicated facilities including group activity rooms,
   Street, Bentley; Rundle Street, Kelmscott; and Kaleeya         podiatry rooms and office suites.
   Specialist Medical Centre, Fremantle. The Kwinana team will    At the official launch of the Midland site, one GP said that
   soon move to Read Street, Rockingham. The new premises         the CDMTs provided a fantastic service.
   enable the teams to deliver existing services and also grow    “My clients’ conditions are complex and the CDMTs do all
   to offer more accessible specialist medical reviews.           the work for me,” he said.

10 Spring Edition 2008
Getting better faster

Would you follow a diabetes treatment plan?
By Jennifer Duff

I was fortunate to be awarded an Australian Diabetes
Education Association scholarship last year to attend a
diabetes conference in Amsterdam.
An incredible 14,000 delegates representing 110 countries
attended the European Association for the Study of
Diabetes Conference. I went to as many presentations as I
could, on a variety of topics, and spoke to many company
representatives about their products.
The most relevant presentation to my work with the
chronic disease management team was by Professor F.J
Snoek, Department of Medical Psychology and Diabetology
                                                               RAI Exhibition and Conference Centre, Amsterdam
at the Royal Netherlands Academy of Arts and Sciences.
The presentation was based on Dr Snoek’s study of              factors such as stress and anxiety can play a part in non-
treatment adherence in diabetes and strongly reinforced        adherence, as can perceptions about one’s health. Poor
the importance of self-management for our patients.            information, inadequate treatment instructions from
For someone with diabetes to adhere to their prescribed        health professionals and dealing with a complex health
treatment requires a complex and sometimes unpleasant          system are also contributing factors.
daily routine. Dr Snoek reported that 30 to 50 per cent of     Dr Snoek recommended a number of ways to improve
people fail to comply with their treatment regimen.            adherence to treatment:
According to Dr Snoek, patients do not adhere                     Technical: simplify the drug regimen, use
to treatment for a number of reasons, including                   once-daily medication.
forgetfulness and allocating their time to other priorities.      Education: teach clients self-management skills and
Some patients decide to stop taking medications due               improve their knowledge about their condition.
to their side effects, while others do not get into the           Behavioural: provide memory aids, reminders, and
habit of completing their full daily treatment. Emotional         financial incentives.
                                                                  Social support: find out why the client isn’t adhering to
                                                                  treatment. They may require help with transport etc.
                                                                  Provide patient-centred care.
                                                                  Respect patient values, preferences and
                                                                  expressed needs.
                                                                  Coordinate and integrate care.
                                                               This incredible opportunity allowed me to reflect on
                                                               how we could improve the effectiveness of our service.
                                                               Increasing our emphasis on listening to our clients’ needs
                                                               and understanding why they do what they do is a good
                                                               first step.
                                                               Attending this conference and particularly this session
                                                               also enabled me to reflect on my lifestyle and ask: How
                                                               would I react to the diagnosis of diabetes? Would I adhere
                                                               to a treatment plan every day of the week for the rest of
                                                               my life? I hope so.
                                                               For more information please contact:
                                                               Jennifer Duff, CNS, Credentialed Diabetes Educator
                                                               Chronic Disease Management Team,
                                                               North Metropolitan Area Health Service
Nga Tran (Vietnamese Diabetes Support Officer) and             ph 0433 899 865 or
Jennifer Duff (Clinical Nurse Specialist).

    Getting better faster

    Home oxygen therapy reducing hospital stays for kids
    with acute bronchiolitis
    Princess Margaret Hospital’s (PMH) latest home-based            safety, parental satisfaction and economic advantage of
    initiative is home oxygen therapy for patients with acute       home oxygen therapy for children with acute bronchiolitis
    bronchiolitis (inflammation of small airways in the lungs).     compared with traditional inpatient hospitalisation.
    The service allows children with stable acute bronchiolitis     Children are referred from the PMH emergency department
    to be discharged from hospital, and receive oxygen              or ward areas and must be stable for 12 hours in hospital
    therapy within the comfort of their own home. Families          before being accepted into the home-based program.
    receive twice-daily home visits and daily phone calls from      Since the service started in May 2008, 28 children
    the Hospital in the Home (HITH) team, as well as access         admitted to PMH with acute bronchiolitis have been
    to a 24 hour telephone line if questions or concerns arise.     referred to HITH and managed at home safely on oxygen.
    Similar to other HITH programs, the acute bronchiolitis         For more information about HITH please call (08) 9340 8379.
    service offers convenience for patients and their families,     References
    and helps decrease demand for hospital beds by treating         1. Shay, D.K. et al., 1999. Bronchiolitis-associated hospitalizations
    children at home when possible.                                     among US children. Journal of the American Medical Association,
    Tommy Dickerson was admitted to PMH with acute                     282, pp.1440–1446.
    bronchiolitis, and discharged into the care of the HITH
    team once stable. Tommy’s mother Tarryn appreciated
    the ability to leave hospital early.
    “Tommy is a twin and I also have another son at home, so
    having HITH enabled my husband to return to work and
    our family to return to its normal routine,” Tarryn said.
    According to PMH specialist Dr Andrew Martin,
    acute bronchiolitis is the most common reason for
    hospital admission in children aged less than one
    year in developed countries. Over the past 25 years,
    admissions to hospital and length of stay have increased
    dramatically, resulting in substantial health care costs for
    health services and individual families1.
    Until now, oxygen supplementation has been the main
    determinant of the length of hospital admission for
    children with acute bronchiolitis, and the need for
    supplemental oxygen is generally considered to be an
    absolute indication for hospitalisation.
    A successful pilot study of the home oxygen therapy
    service was undertaken in 2007. This study assessed the        Tommy Dickerson with HITH nurse Julie Audas

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12 Spring Edition 2008

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