Cancer Care

okay last up cath adams senior psychologist from john hunter hospital in newcastle andcath's going to present integrating a multidisciplinary steppedcare model of psychosocial care for cancer survivors and families intoroutine clinical practice in rural and remote regions thanks team i just like saythat title wasn't all mine i guess it's being said often enough so fartoday but

the bucket's empty there's no more moneyto be had in the current climate and so if we really gonna provideadequate timely appropriate psych-socialintervention we just need to change the way we manage our work load and the way we refer patients sobefore i get into the project i need to acknowledge the fact that within hunter new england we're veryfortunate in that we have a psycooncology clinical stream that's part ofthe cancer services stream i recognize that all local health districts out that lucky

and certainly the support that we getfrom the cancer services directorate has made all of this work possible i alwaysgo over time so i'm doing the important things first i'd like to thank all of mycolleagues being involved project would never have worked without deanna sue who's the clinical nurse consultant that i work with inpsychoncology and she's the most organized person inthe world i am her antithesis the social workers that we worked with fiona in armidale, jan in moree, judith in taree, lee

in tamworth and i'll talk alittle bit more about the the psychoncology positions thatexist within the area our fearless leader brian kelly who isthe stream director for the clinicalpsychology stream the cancer directorate people who are nearly all here in the room butparticularly all of the staff the volunteers the gps the practicenurses and all of the interested parties who participated in this project and were part of developingthe model of care that i'm going to talk to you about

so thanks to judy you all know about hunter new england we are very concious in our local health district of the tyranny of distance we have a combination of that and the knowledge that there is no newresources we recognize that typically rural areas have high levels at generalist supportacross-the-board particularly in psychosocial support butpoor levels a specialist support so within the hunter

new england the dedicated psychoncology social work positions that existed are the four people that i'vementioned there are actually three full-time equivalent positions so tareetamworth moree and armidale there are nodedicated clinical psychology or psychiatry positions outside of newcastle that already you can already seethe disparity in the availability of specialist servicesso what we're looking at is how we could introduce a model of care that was generic across the area butcould be localized to the specific

networks we recognize it was crucial to involve all of the local members and so wereally did start this project from the ground up we looked at the model of care withinthe psychology clinical stream and we haven't reinvented the wheel we'vebuilt on other people's work but that was actually accepted by thestream before we then went out and built the networks also the the need to develop strongrelationships and we've worked particularly hard to tryand identify all of the people across and

the networks that might be involved in psychosocial care we were conscious of the fact that a lotof those people are quite isolated a lot of sole practitioners and so part ofthis project was also looking at how we could provide support for those people across the districtso that supporters were actually beingsupported in their service provision so the stepped care model what is it? it basically looks at allowing you to tailor the interventionto the level of potential need for each

patient and it might be a cancer patientit could be their carer it could be a family member and it involves the steps of identification so you can see that universal care down the bottom that covers everybody all patients withcancer and their supporters should recieve universal care when you step up the model you looking at people thathave higher levels of emotional or psycho-social distressoften higher levels of support needs and at the toplevel we have the people with severe or

moderate levels of distress who need quite specializedpsychosocial intervention so the aim behind it is to firstlyidentify patients need we use the distress thermometer i'll talk a little bit more about thatlater on it's really important to remember the basis of this model isn't screening screening is a process it's not anoutcome screening people and finding out whetheror not they are distresses

isn't the endpoint it's just thebeginning and so this model is about how do you make sure the people end up ina different tiers recieve the care that they need so we were having to look at thefull range of existing resources recognizing that the same patient canstep up and down through this model during the journey soassessment and monitoring are really important it'snot a one-off thing um as i said we haven't reinvented thewheel this works been around for

a while what we've done is try to buildon some work that came out of the western australian model of psychosocialcare and that's how we've developed ourgeneric model and i apologize for its tiny and you cannot read any of itbut basically it this path way steps you through thepyramid so all patients diagnosed with cancer arereceiving universal care at the point of entry to the cancerjourney so often the gps are that point of entry and soit's been really important to try and involve them

the generic pathway talks about what universal care is and then steps downto patients that are identified as distressed so for the distress thermometer that score 4 or abovethere's a level of triage that exists within here so youidentifying the patients that actually that then might need a psychosocial care plan and if they do your then again triaging what level of care they need the most important thing is this is not a static process it's a living process and it's important thatthere is a repeat assessment throughout the person's journey so thatwe kicked checking in with people and

looking at how they doing so the aims to the project it came outat the psycholoncology stream and recognizing firstly that we needed a model ofcare that we were all providing care but in slightly different ways and notnecessarily for the patient that wasn't adding to their sense of consistency when they went back home or when they came to visit the major cancercenters so we decided on accepting this tiered model butthen looking at how we could localize it so that it actually related

to the people in the home town of the patient we made it very clear that we wereusing existing resources we've begun all of our conversations with the bucket isempty there's no i promise of extra resourcesin this at all but we need to talk about the resources we got how we can betteruse them we did try to use the psycho social care matrix which is a evaluated tool to look at psychosocial care provision but just was tooconfusing for the people that we're talking to so we gave up on that

and i wouldn't use it for that reason we are particularly interested inlooking at improving access for the high priority populations and particularlyfor aboriginal populations and recognizing again the isolation of the health careprofessionals from support and training we actually asked them what sort of training they would like and what sort of support from us and build the plan around that we also wanted tolook at developing the service pathways thatactually allowed

people working with cancer patients andtheir families to identify how and where this person can get the helpthey need when they need we've also been looking at using technology and ipad and howwe can use and to increase face to face contact both in terms of patient to doctor patient toclinician patient to counselor patient to psychologist patient to family and also using themfor clinical supervision so providing individual supervision with people

using skype its a secure video conference that thats still in that developmentalprocesses we are particularly concernedas i said with the with the local aboriginal peopleand and the distant aboriginal people and our health district is very much looking at every way we can. to close the gap and as as i said to someone the other day who wasquestioning why we needed to have that

frame work if you don't see why we desperately need to close thegap just try jumping it the method that we used is we identified the local networks based on the clusters which were in judy's map and i'll show you againin a min we did organize workshops in armidale and taree we were hoping to have workshops inmoree and muswellbrook but they haven't happened yetand i'll talk a little bit about why we had the communication skills andeffective partnerships training in tamworth

so we really made an effort to go to theareas and that's something that often ithink we forget to do when we working with people that come from differentareas the importance of going to visit them particularly for colleagues working inrural and remote areas it's really important to actually say wewill come to you it's not that hard considering that we we've known for some time tamworth did a project

probably 15 years ago with louise sheppard out of prince of wales looking at clinical supervision usingvideoconferencing we know that that works so it made sense to try andbuild on that with gyne oncology we do consultations to the distant areas aswell so we knew the telehealth worked just trying to look at how we canincrease that ease of access into the home or into the office so here's the mapagain the red circles are the places that we that there's a person that's lookingafter the network is placed so you can see

moree it's actually 7 hours when youdrive to the speed limit and it's not very clear there but they havea halftime social worker and a medicaloncologist who visits from tamworth armidale is 4 hours from newcastle where the major treatmentcenters are they have a a half-time socialworker and their medical oncology and radiation oncology services are private. they come from royal north shore private

tamworth has a regional cancer centreand has made a huge difference to services provision they have one full-time social worker hematology medicalradiation oncology on-site no psychology no psychiatry no physiotherapy taree is two hours away they have one full-time social worker and a medical oncologist on site and muswellbrook is and an hour and forty minutes away so they have no social worker medical oncology support is

from both newcastle and tamworth so it's all different it'sall a bit confusing probably more so for the people thatlive in those areas so what we did we we organized a network meeting so of the two one was in armidale and one was in taree we had 57 people attended they included the localsocial workers cancer care coordinator oncology nurses gp practice nurses gp's support groupleaders cancer council came other ngos private practitioners in the localareas and some of the local charities

as you can see everyone talked about the theincrease in knowledge that they gained about the localservices it was really interesting have all of the people from the localarea in the one room going i didn't know you did that so can we access that the fact that at the end fewer people felt very confident about making a referral we actually took as a positivething because there's a bit of over confidence abouthow easy it would be to accept access these services if you needed to

it was perhaps a littledistressing when we talk to people about how they manage the high levels of need and the people who needed the specialized care so what happens then i don't know so therewas a disconnect for the people at the top level of the people that attended 15 of themwere using telehealth 9 of them said that they would now useit again i think that was a good outcome the 4 that said they wouldn't werebecause two of them were practice nurses and didn't see it as part of their role

one of them didn't have access to thetechnology and one of them just wouldn't try it was interesting the main outcome from the main was the gppushing for service directories and when we talked about the fact thatthe cancer council had service directory and that can refer exists they werevery dismissive of those facts and saw them verymuch as top-down things so these directories were put together and then other people had to putthe information in and make it right and and i know myself i'm apparently member becolorectal multi-disciplinary team at

gosford hospital according to canrefer i didn't know that as far as the professionaldevelopment went we ran a workshop where we had janet vickers the head of social work for family and community services on the centralcoast come talk about effective partnerships she was awesome she's actually managedto get dax and juvenile justice and the police service was working together

and one other things that shehighlighted was instead of sitting in our silos looking at how we can build partnershipslet's step into the middle of the room and look at what we can achieve together that was a very positive outcome and ithink particularly for the northwestcancer centre which is a new service it really helped them look at how they couldbe supporting each other particularly throughchemotherapy and radiotherapy so that was good the communication skills we had

stewart dunn so that was fantastic itwas slightly different in that we had all different disciplines withinthe room and it was following one patient throughtheir journey and one of the most positive things that came out of thatwas different disciplines realizing how much more power they had to work withtheir colleagues rather than youknow seeing patients in a linear progression particularly the care coordinaters and social workers actually sitting in and practicing working with apatient together they found that very

positive the service directories is still atdifferent stages and this is what the gps wanted we went there thinking we would bedeveloping pathways that they were at that point and they weren't they just wanted to know who they can refer to where this is an example of what we sent back to armidale, we've filled in what we talked about on the eveningwe filled in some generic leukemia foundation camp qualitythings that exist across the area but also somespecific services within the hospital

within the private practice world and what they could do to access thosehighlevel service needs so looking at telehealthusing scopia touching in with the see a psychiatry teleconferencing system that we use we sent that back to them and that the socialwork from armidale actually couldn't make it on the night which is a greatdisappointment but the outcome from that is that the local charitywho did make it on the night are supporting the development of thewebsite and have taken on the championship

of owning the website and making the changesin updating it and that's something that we really pushed as well you know we willhelp develop the networks but someone in the area has to be responsible for keeping them up to date again getting the service director together is aprocess not an outcome it's an ongoing thing it needs to to keep being reviewed in terms of reactions and how people responded to itwas the the reaction were very positive webuild a lot of

new partnerships i think was verydifficult to get the gps to attend but they are flat out from the taree workshop we invited 76 gps 5 them said they were coming and one turned up and one comment was that it would be nice if you involved the gps so what we've foundfrom that by then going back to the gps and talking to them is what they want is a draft service directorythey'll comment on that they want a useful tool they don't want towaste time talking about what it might

look like and i can understand that the point of entry screening is hard and i don't know that the distress screening isactually providing a barrier to implementingpsychosocial care i think this is something across the board we need to discuss does does using a tool like the distressthermometer give us more than just encouraging people to ask the patientshow they're going does it put a barrier in place does it add an extra step that's just too hard something else to remember i thinksome of the advantages with what we've

done is everyone can see what what they own and i cansee what they've contributed to you but i can also see that they benefit from thewhole process and that it benefits across the area we have had good buy in from the people that attended and we areintending to provide ongoing support one of the difficulties that we have is that the deanna's position and my position is notrecurrently funded so we have to really have to work hard by next november to makesure that it's its integrated an

accepted the generic model of care and service pathway i think are widely applicable and i think it's something that couldeasily rolled out across the state in terms of our future goals first onealways been a personal goal of mine but we might just start with the localhealth area perhaps moving on to the state we are working we're hoping to workwith the aboriginal health service in taree

one of their nurses came and attended our night at taree asked a couple questions and said it'sthe first time i've ever attended something i felt comfortable enough to askquestions and talk at so we thought that a really positivething we working to tie it in with the healthcare pathway hunter urban medicare local has they're basicaly a screen that the gpcan pull up that tells them if they suspect this they do the followingthings so just putting ours into that smae format we've got

amended drafts out to all of thenetworks in terms of their service directory and we're getting feeback on those we are also introducing monthlysupervision learning sessions by telehealth which is something the staff have reallyresponded to well and that's not something that costs us anything to do we do recognize the need to take it stepby step and make use of opportunities as they arise and so the monthly learning sessionswere actually just supervision sessions but staffexpressed interest in learning a bit more

so that's what we're doing with them we're confident that the networks willcontinue and patient access to appropriate and timelyservices will continue to improve we recognize itdoes take effect but we have seen acceptance from all of thedifferent networks that we've established that if everyone does theirlittle bit the whole will be better and patient carewill be more consistent and better for everyone across the areathat's the end. thanks for listening