OUTCOMES OF THE
RVEEH/ACO COLLABORATIVE
WORKFORCE PROJECT
GP-Hospital Liaison Officer
Conference 2013
Neville Turner, Jonathan Jackson, Jacqui Beltz
Questions?
1. Can you identify a program with
pressures on service delivery?
2. What options for ‘doing something
different’ are available?
Background
• Royal Victorian Eye and Ear Hospital
(RVEEH)
– Specialist public hospital in Melbourne >250k
patients
– Secondary/tertiary care provider
– receives around 10,000 new referrals for
ophthalmology services every year (50-60 week
wait)
– approx 50% are from general practice
• Previous audit suggests that 31% of
these referrals could potentially be
treated in the community
Background
• Australian College of Optometry (ACO)
– Not for profit provider of public optometry
services
– 6 sites metro Melbourne (plus outreach), 50
EFT optometrists (skilled workforce)
– 26+ consulting rooms and capacity
– Primary optometry care and
subsidised visual aids
Background
• Aging population
– Increase in need for services
– demand for eye health workers is likely to
increase in the future
– Current models / barriers to care / professional
boundaries need to be re-evaluated
• What patients are referred to hospitals?
• What patients should be referred to
hospitals?
Aims
• To develop a sustainable public model
for provision of integrated care between
Ophthalmology and Optometry
• Implement a pilot clinic
• Provide enhanced training opportunities
for optometrists
• Determine refinements to the proposed
model
Team
•
Steering Committee:
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Ophthalmologist:
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Dr Jacqueline Beltz
ACO Optometrists:
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Dr Mark McCoombe, Dr Michael Coote, Dr Jacqueline Beltz, Dr Richard Stawell, Dr Anne Brooks, David Lau,
Dr Lina Nido, Stephanie Tsonis, Patricia Bruce, Kathryn Day, Neville Turner, Tim Fricke, Jonathan Jackson,
Sarah Hosking
Genevieve Napper, Lisa Lombardi, Leanne Nguyen, Adrian Bruce, Joseph Choi, Iris Huang, Roman
Serebrianik, Josephine Li, Danielle Zheng, Janelle Scully
Contributors:
–
Prof Jill Keefe, Jennifer Hassel, Vicki McSweeney, Tenille Ibbotson
Objectives
• Improve patient care and access
• Reduce waiting times for new patients
• Increase capacity in the community and tertiary
setting
• Improve utilisation of existing skilled
community workforce
• Reduce gap between supply and demand of
health workforce
• Establish an enhanced model of eye health care
in Australia
Model
• Funding support from Workforce
Innovation Grant, Department of Health,
State Government of Victoria
• Weekly clinic for 6 months at ACO
• Identified pool of practitioners
• 5 optometrists (later increased to 8) to 1
ophthalmologist per clinic
• Ophthalmologist to review all cases
• Review/teaching opportunity at end of day
Methodology
• Criteria developed to identify eligible referrals
Inclusion
•
•
•
•
•
•
•
•
•
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GP referral with unclear but non-urgent diagnosis
Not specified medical or surgical intervention
Blurred vision
Eye review
General eye check
Diabetic eye check
Dry eyes
Itchy eyes
Floaters with no other symptoms
Eye check due to family history e.g. glaucoma, AMD
Exclusion
•
•
•
•
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Clear diagnosis
Lid lesions/abnormalities
Rural/location
RVEEH specific medical or surgical intervention
required
Children < 18
• Retrospective triage of GP referrals on General
Eye Clinic (GEC) waiting list
– had been waiting up to 18 months
– Towards end, new GP referrals to RVEEH
immediately triaged ie no waiting list for identified
patients
Quality Control
• Development of evidence based clinical
guidelines and referral pathways for
commonly referred eye conditions
– ARM
– Cataract
– Glaucoma
– Diabetes
– Blepharitis
– Dry Eyes
Number of GP referrals
reviewed for triage n=3,937
Eligible referrals based on
triage criteria
n=1,350(34%)
Ineligible referrals based on
triage criteria
n=2,587(66%)
Removed from W/L (unable
to contact patient)
n=457(34%)
Accepted n=833(62%)
Declined n=60(4%)
Attended
n=686(82%)
Cancelled
n=58(6%)
DNA n=89(12%)
Rescheduled
n= 28(47%)
Discharge to ACO
n=378(56%)
RVEEH review
n=195(28%)
No other appt
n=32(53%)
Rescheduled
n=77(88%)
Discharge to GP for
ongoing care n=16(2%)
DNA x2
n=11(12%)
Discharge no follow up
care n=97(14%)
Exclusion (2,587 patients)
•
Clear diagnosis
•
63%
•
Lid lesions/abnormalities
•
14%
•
Rural/location
•
9%
•
RVEEH specific medical or surgical intervention
required
•
6%
•
Children < 18
•
5%
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Other
•
3%
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Cataract 68%
Pterygium 12%
Glaucoma 7%
Blocked tear ducts 4%
Other 9%
The patients
• 686 patients attended ( of 1350 identified as eligible)
• Main presenting complaint
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–
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blurred vision (n=279, 41%)
Dry eyes (n=91,13%)
itchy eyes (n=69, 10%)
watery eyes (n=69,10%)
floaters with no other symptoms (n=91, 13%)
difficulty reading (n=101, 15%)
• 39% of patients reported previous ocular disease (n=265)
– 53% of these had either unilateral or bilateral cataract
surgery (n=141)
• 31% of patients reported diabetes (n=212)
• 8% reported ocular related family history (n=57)
• 73% of patients reported using current medications
for systemic conditions (n=503)
– 48% hypertension (n=330)
– 32% high cholesterol (n=217)
• 16% reported use of current ocular medications
(n=108)
– 83% lubricants (n=89)
– 8% anti glaucoma agents (n=8)
• 72% of patients attending the clinic reported having
a pair of current glasses (n=493)
Patient Outcomes
Discharge to ACO
Refer RVEEH
Discharge to GP
Discharge
378 (56%)
195 (28%)
16 (2%)
97 (14%)
88% to general clinic
28% 1-6w, 61% 12m
GP to refer to local optom
Diabetic eye screening
84
Cataract
50
Glaucoma suspect
63
Other
45
Cataract
51
Diabetic retinopathy
±CMO
23
Refractive error
50
Glaucoma suspect
32
Dry Eye
29
Posterior capsular opacity
13
Blepharitis
27
Lid abnormality
10
Other
26
Blocked tear duct
9
AMD (Dry)
16
Glaucoma
8
Posterior vitreous detachment
12
Epi-retinal membrane
5
Epi-retinal membrane
11
Choroidal naevus
9
2 year review
Key findings
• 34% of GP referrals received at the RVEEH
are suitable to be seen in the community
(based on inclusion criteria)
• The top three reasons for referral:
– 26% blurred vision (n=178)
– 19% diabetic eye check (n=130)
– 13% general eye check (n=93)
• 72% of patients were discharged from
RVEEH after assessment at the pilot clinic
– Never had to attend hospital
• 56% of patients seen discharge to ACO most common clinical outcome (n=378)
– Diabetic screening was the top reason for
ACO review (n=84, 22%)
• Only 28% of patients required further
RVEEH review after assessment at pilot
– 29% these had direct access to sub-specialty
clinics
Impact
• Positive impact on the trend of wait time for
first appointment in General Eye Clinic (GEC)
• In April 2012 shortest wait time for GEC in last
12 months
– median wait time reduction
of 12 weeks
• Improved access for new
patients
• Contributed to a 130%
increase in the GEC patients
seen at RVEEH
Key Outcomes
• A successful triage process for non specific and
unclear GP referrals
• Significant impact on reducing the RVEEH GEC
waiting list and the number of new patients
attending the GEC increased
• EACO provided a direct pathway for patients in
need of RVEEH GEC and Special Eye Clinic (SEC)
services
• Step in improving workforce capacity and
productivity by improving the utilisation of the
existing skilled optometry workforce at the ACO
• No clinical risks, adverse events or patient
complaints were recorded throughout the trial.
Patient Feedback
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78 (11%) patients interviewed
97% rated the quality of care as excellent or very good
94% were satisfied with the outcome of their appointment
97% were happy with the time spent with the Optometrist
to discuss eye problems
• 95% found it convenient to travel to the ACO
• “I was impressed as I have had a lot to do with the public
system and this was the best public experience I have had
to date”
• “somebody is doing something to make things better and I
could see that”.
Optometrist Feedback
• 88% very satisfied with their involvement in the
project
• 100% benefited clinically working alongside an
Ophthalmologist
• 75% benefited from post clinic tutorials, all would
like to continue, with a focus on clinical cases
• Responses support a theme of “Right Care, Right
Setting” and the opportunity to “introduce patients
to the optometry profession”
• 100% would like to be involved in this model of care
in the future
GP Feedback
• 94% of GPs were very satisfied or satisfied
their patient was involved in the project
• 44% had never referred directly to the ACO
• 94% would occasionally or frequently
consider referral to the ACO in the future
• 38% definitely and 56% possibly believe
their referral practices will be influenced by
this project
Lessons Learnt
• A clinical champion and early stakeholder
engagement is critical to the success of the project
• The readiness and willingness for change needs to
be acknowledged
• Improved utilization of existing skilled workforce
in the community can improve access to tertiary
care
– Look beyond existing referral pathways
– Understand skills of providers
– Best option for the patient
• Established relationship between the ACO /
RVEEH has set the scene for future collaborations
Recipe for success
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Right idea, right time, right people
Clinical and administrative champions
Champions work in program
Steering committee
Be prepared to compromise
Next Steps
• Review of eligibility criteria to include more
conditions e.g. pterygium
• Review and expansion of clinical
guidelines/protocols and referral pathways to
include management of more conditions e.g.
choroidal naevus (12 in total)
• Feedback to GP to change their referring habits
– Challenges include access, communication, new
(non medical) model
• Establishment of ongoing joint clinic at ACO
ACO / RVEEH Clinic
• Ongoing clinics started in November 2012
• Runs every 4 weeks
• Pool of 15 optometrists and 4
ophthalmologists
• Expanded referral criteria
• Different funding model
• Booking straight into RVEEH clinics as
required
• Issues with funding for interpreters
Acknowledgements
• Department of Health, State Government of
Victoria
• Steering Committee and staff involved
• Royal Victorian Eye and Ear Hospital (RVEEH)
• Professor Sarah Hosking, Tim Fricke (ACO)
• David Lau, Stephanie Tsonis (RVEEH)
• Professor Jill Keeffe and Jennifer Hassell,
Centre for Eye Research Australia (CERA)
• Jacqui Beltz and Stephanie Tsonis