Models of Access and Clinical Service Delivery for People with HIV in Australia project

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Stephanie McLean outlines a project which mapped models of access and service delivery for PLHIV. This presentation was given at the AFAO Positive Services Forum in June 2009

Stephanie McLean outlines a project which mapped models of access and service delivery for PLHIV. This presentation was given at the AFAO Positive Services Forum in June 2009

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  • ARCSHS HIV Populations in Australia- implications for access to service and delivery- requires a particular approach to characterisation of key sub populations- with the focus not simply on analysing populations at risk but on the nature and shape of specific interactions and interventions. General patterns can be drawn in how underlying health, social, cultural and economic issues inter-relate with service demands in these sub-populations. 2 important emerging issues are potential changes in patterns of geographic location of the HIV positive population and changes in how and what type/style of services are accessed or wanted. Further research is required in relation to emerging trends and projections in the HIV positive population, and the implications for service planning and delivery


  • 1. Models of Access and Clinical Service Delivery for People with HIV in Australia project AFAO Positive Services Forum June 2009
  • 2. The problem (1)
    • Client group is changing
      • increasing in number with continuing new cases and increased life expectancy and therefore ageing
    • Clinical response is changing
      • increased complexity
      • increased ambulatory component of care
      • changed population with different needs and clinical course
      • HIV as a chronic condition
      • Co-morbidities
    • Social and psychological health effects
  • 3. The problem (2)
    • Workforce is changing
      • ageing, recruitment, retention, replacement & training, practices
      • General health workforce
      • HIV specific workforce
    • Health systems
      • Tailored to acute and hospital based problems
      • System changes (PHC strategy, PHT, National HIV Strategy, Chronic Disease Strategy etc)
      • State, Territory, Commonwealth
    • Global financial crisis
    • Data, assumptions and projections.
  • 4. Response
    • Overseen by BBVSS and Commonwealth Ministerial Advisory Committee
    • Advisory Panel
    • Steering committee
    • Project officers
    • Funded from late July 2008
  • 5. Problem analysis
    • NAPWA and ARCSHS
    • Models of access to and clinical service delivery for:
      • HIV in Australia
      • HIV internationally
      • Chronic disease
    • Service mapping
      • Health services and HIV services in Australia
    • Workforce issues
  • 6. Problem analysis
    • Methods
      • Literature reviews
      • Questionnaires and interviews: phone, email, face-to-face
      • Requests for data
    • Issues
      • completeness, currency, evidence base, generalisability
  • 7. HIV populations in Australia – implications for service access and delivery
    • Increasing, ageing, treatment and co-morbidity issues
    • Geographic trends
    • Mental health
    • Stage of HIV treatment and service needs
      • Location
      • Pharmaceuticals
      • Other services
    • Key sub-populations (relates to above point)
  • 8. ARCSHS concludes
    • Two important emerging issues:
      • potential changes in the patterns of geographic location of the HIV-positive population
      • changes in how and what type/style of services are needed, wanted or accessed
    • Key issue remains tailoring medical and other service delivery to individuals
      • requires a balance between mainstream and HIV-specific services in particular areas
  • 9. Themes and Chronic Disease (1)
    • Policy and funding support and change
    • Patient (and carer) centred
    • Spectrum of responses from prevention to end-of-life
    • Key role of community
  • 10. Themes and Chronic Disease (2)
    • Health systems
      • multidisciplinary, integrated, coordinated, flexible, planned, evidence based and supported
    • Clinical information systems:
      • evidence based guidelines, health plans, recall, reminder and follow-up systems
    • Delivery systems
      • self management, shared care, nurse practitioners, supported or comprehensive care, referral pathways and access to primary and specialist and multidisciplinary health care, hospitalisation, rehabilitation, palliation and end-of-life
      • Workforce – recruitment, retention and training
  • 11. Recurrent themes (HIV and Oz)
    • Service access: geographical and cultural
    • Service delivery: re-oriented, integrated, coordinated, patient centred, multi-disciplinary
    • Planning – strategic, coordinated, consultative
    • Information management and communication technology
    • Workforce – GP, development
    • Evaluation and research
  • 12. Themes and International (access)
    • Service models – multi-disciplinary, dedicated case managers
    • Application of health information systems
    • Physical access
      • Location, geographical proximity, out of hours, access to appointments short waiting room time
    • Free services and ART
    • Perceived quality of care and service availability
  • 13. Themes and International (service delivery)
    • High patient caseloads
    • Services conducting clinical trials
    • Case management
    • All associated with improved clinical outcomes, HAART use and continuity of care
  • 14. Themes and International models
    • Patient centred care and continuum of care
    • Chronic care models:
      • self management, case management, integrated multidisciplinary teams,
      • coordinated delivery systems
      • effective health information systems
    • Response to co-morbidities (mental health, D&A)
    • Response to non-clinical health determinants such as housing, employment
    • Insufficient evidence: need for evaluation and research
  • 15. HIV services in Australia
    • What is done, where and by whom?
    • GPs and s100 prescribers
    • Sexual health clinics
    • Secondary and tertiary services
    • Aboriginal health services
    • Mix is different in different parts of the country (state, town, suburb)
  • 16. Models within models
    • Self management
    • Case coordination (supported to comprehensive to intensive management)
    • Shared care
    • Other support/management services: multidisciplinary
    • Supporting non-HIV specialist (eg managing dementia and stroke)
    • Remote (primarily) services:
      • Specialist advice and mentoring
      • Telemedicine
      • Phone links
      • Fly in; fly out
      • Patient evacuation
  • 17. Themes and Workforce (1)
    • Generally: undersupply, ageing population, increasing part-time work, trend to specialisation for doctors and nurses, silos for practice and training, problem of too few training places
    • Barriers to recruitment, retention and training in HIV sector
    • Barriers to enhanced primary health care (eg mental health, ageing, D&A, case management, multidisciplinary teams)
  • 18. Themes and Workforce (2)
    • Strategies
    • Financial and “lifestyle” incentives
    • System change and support for change
      • Enhanced PHC, multidisciplinary, shared care
      • Mentoring
    • Other areas
      • Rural and remote
      • Indigenous, CALD: patient journey issues
    • Training
  • 19. Themes and Workforce (3)
    • Mostly untested
    • Need effective and sustainable interventions
    • Good data and continuing evaluation and research
  • 20. Demo project 1: Shared Care
    • To explore mechanisms for facilitating and delivering shared care in the community
    • To determine the features of community provided shared care & who is referred for this level of care:
      • Level of patient need
      • Level of practitioner training and where delivered
      • Role & frequency of specialist review
      • Other contributors (nursing, practice nursing, CBO)
    • To determine and develop a range of community provider supports
  • 21. Demo project 2: High caseload s100 prescribers
    • To develop and implement a series of tailored supportive solutions to support individual high caseload community practices
    • To evaluate outcomes related to provider recruitment and retention
  • 22. Demo project 3: Nurse based initiatives
    • To explore, implement and evaluate a range of nurse based strategies aimed at increasing access to clinical service delivery
    • These may include:
      • Practice nursing
      • Nurse practitioners
      • Community based nurse models
  • 23. Other priorities (X 5)
    • To implementation and evaluate
      • strategies aimed at increasing the linkage between laboratory and clinical settings
      • innovative strategies for linking with patients and with doctors at time of diagnosis
    • To support, implement and evaluate
      • e-health strategies
      • communication between services
      • self management strategies and exploring these in tandem with above priorities
  • 24. Supporting & enabling recommendations
    • Additionally, enabling and supporting priorities that emerge from the National HIV Strategy
    • Fundamentally
      • The support of routine and longitudinal data sets such as ARCSHS
      • The expansion of the AHOD data set
      • Continuation of the joint BBVSS/ MACASHH committee overseeing this project to act as implementation oversight group
  • 25. Conclusion
    • Comprehensive piece of work which provides a solid evidence based platform for further work
    • Responded to many issues and raised many more questions
    • Need for further work (as demo projects highlight)
    • Need for strategic action given demands arising from current health, social and international change and pressure