Chronic health conditions are leading contributors to the disease burden in Australia. It is estimated that half of the adult population have at least one chronic health condition and rural Australians displaying a higher prevalence of chronic disease. People living in rural Australia arguably have the most to gain from better prevention and management of chronic disease through primary care. Another barrier associated with chronic disease management includes timely access to pathology results. Innovative and collaborative models of care are required to address the complex challenges and barriers associated with chronic disease management.
The My Health Point of Care Innovative Technologies Trial (PoCiTT) Program was developed with funding from Country SA Primary Health Network’s (CSAPHN) to offer additional support to South Australian rural GP practices to address chronic health disease. The My Health PoCiTT (MHP) program has two individual, though strongly linked, support tools:
Point of Care Testing (PoCT)
PoCT enables GP practices to perform pathology testing on site, obtaining a result within 15 minutes and being able to act on that immediately. This removes the inconvenience of the patient having to go elsewhere for blood collection and then arrange another appointment with their GP to discuss the results. This quick turnaround encourages streamlined patient management.
The tests offered in this program were NT-proBNP (heart failure), HbA1c (diabetes), Lipids (cholesterol), CRP (antibiotic prescribing) and Urine ACR (kidney disease). Training for staff was provided on site and on-going support was provided. All testing was performed within a quality framework, ensuring accurate results.
Virtual Home Monitoring (VHM)
Home monitoring for chronic disease has been shown to reduce hospital admissions and enable patients to have a more active role in the management of their disease. VHM enables GP practices to closely monitor patients with chronic disease such as heart and lung disease, high blood pressure and diabetes. VHM kits include a smart tablet and peripheral devices (pulse oximeter, blood pressure monitor, blood glucose monitor, weight scales and thermometer), to be utilised in any combination, dependant on patient condition and GP referral. The results and responses to clinical questions are automatically transmitted to the tablet, which then uploads to a database which is monitored by health professionals. Any abnormal results or responses that show a worsening of the patient’s condition are referred back to the GP practice, where staff can contact the patient and determine the best management going forward.
Implementation of the program began in June 2018 and has since been rolled out to 18 GP practices with the aim of improving health outcomes and reducing hospital readmissions. Over 150 patients have been monitored on the VHM program and more than 2,000 PoCT pathology tests have been performed. Survey feedback from the GP’s, nurses and patients has been overwhelmingly positive about the impact of the program.
The MHP program has been able to harness technology through VHM and PoCT to be an effective strategy to help support rural general practices to manage their chronic disease patients, in turn improving patient outcomes. The MHP program has recently received extra funding from the Country SA Primary Health Network’s (CSAPHN) to expand the services until June 2021 and we are excited to further improve the program and offer it to more sites in rural and remote South Australia.