Planners Forum
Melbourne 2011
Nicole Cameron
Current Situation

Department of Health



Health Reform – opportunity for change



New CE
formation of Department of Families
Structural changes underway – staged approach
Only at the beginning (11 April 2011)
Service Planning




Historically more of a ‘silo’ approach
Need for integrated planning (continuum/ clinical/ infrastructure)
Likely an official Departmental Planning Unit will be established
Meanwhile work is underway…
2
Northern Territory – it IS special!

Population Context






Population Health (BOD)





Large geographical mass sparsely populated
Small resident population with historically younger profile
30% Indigenous people (2.4% Nationally)
70% Indigenous people live in remote/ very remote areas
Greater proportion of Low SEIFA values than any other jurisdiction
Lower life expectancy than any other jurisdiction
Highest BOD amongst all jurisdictions
NT indigenous BOD 3.57 times higher than national average
NT non-indigenous BOD 1.22 times greater
Activity


Small proportion of population account for high usage of services
ASH - Over 66% inpatient Indigenous & over 80% ED presentations
3
From today…

Political Context


Close political environment
Territory 2030 – strategic direction for major services

Health services will be easier to access for all
 Access to services will be at a similar level as other states
 New Hospital in Darwin



Multiple stakeholders (AMSANT/ GPNNT/ Remote)
Have commenced integrated planning (noting last point)
Challenge for the NT:



‘Purist’ influence - service planning technical tools
Pragmatic approach – in the NT context
Creative implementation – multiple challenges (often conflicting)
but necessary to think differently and apply national and
international learnings to meet these ‘special’ needs
4
Creativity in implementation
An example for today:
RENAL SERVICES IN THE NT
5
The Problem



High Chronic Disease and increasing ESKD
Majority from remote community (85% all dialysis patient
are Indigenous people)
Centralised service provision



Poor access to health services
Limited access to specialists
Poor management of CKD

Prior to CTG/ intervention

Poor psychosocial preparation for treatment

We needed to think creatively in the context of the
Territory, the patient and also of best practice
6
Growth Industry
NT Prevalence ESRD 1997 - 2009
600
CA
TE
Total
500
400
300
200
100
0
7
8
9
0
1
2
3
4
5
6
7
8
9
c -9 ec -9 ec -9 ec -0 ec -0 ec -0 ec -0 ec -0 ec -0 ec -0 ec -0 ec -0 ec -0
e
D
D
D
D
D
D
D
D
D
D
D
D
D
7
19
92
19 /93
93
19 /94
94
19 /95
95
19 /96
96
19 /97
97
/
19 98
98
19 /99
99
20 /00
00
20 /01
01
20 /02
02
/
20 03
03
20 /04
04
20 /05
05
20 /06
06
20 /07
07
20 /08
08
/0
9
Treatment Numbers
Growth in Renal Replacement Therapy
NT Dialysis Treatments 1993 - 2009
60000
50000
CA
TE
Total
40000
30000
20000
10000
0
8
Modality Uptake
NT Renal Replacement Therapy 1997 - 2009
600
Patient Numbers
500
400
HD
PD
300
Tx
200
100
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
9
Projected Treatment Modality Uptake
Projected ESRD Prevalence According to Treatment
Modality
Patient Numbers
900
800
700
Transplant
Home HD
600
Sat HD
500
400
Hosp HD
300
CAPD
200
100
APD
08
0
2
10
0
2
12
0
2
14
0
2
16
0
2
18
0
2
10
Community of Origin
11
Focus of NT Renal Services

New Strategy and Service Plan Development


Coordination with Remote Health DCI, AMSANTS, AG and NGO
Improved Care Coordination - identification and case
management

Public Health RN and IT integration
 Case Conferencing and Outreach CKD clinics
 Resources
 All options available (palliative care/ renal project)

Decentralise and decrease demand for satellite services
Supported PD – hostel accommodation (Mid 2011)
 Home and community based HD (self care – relocatables/ RRR)
 Smaller regional facilities


Finding viable solutions

Supporting people to be independent in their care
 Opportunities for treatment closer to home (reverse respite/ renal bus)
12
Building in Program Flexibility
Infrastructure
Client’s home
 Renal Ready Rooms
 Aged Care Centres
 Relocatables

Simple systems



Safely contained
Easily maintained by client
Minimal need for
intervention (promote
independence)
#3x3 area
#1 chair up to 4 people
#Capacity for 1 or 2 chairs
13
Training Program
Training Agreement

Client responsible for treatment

Client agrees to attend all training sessions

Client trains partner

Competency Checklists
Interpreters
Community Consultation (up to 3 visits)

Community Health Centre Staff

Local Shire Staff and store managers if required
Community Partnership Agreements
Client and Staff Support

Hot Line

Regular site visits
14
Community-based Home HD Services
Home Training Unit
Darwin and Alice Springs
– 2 stations
WDNWPT Reverse respite - 2
stations –A/Springs, Yuendemu,
Ntaria and Kintore
TIWI
ISLANDS
GROOTE EYLANDT
Home situation – Darwin x 3
Wadeye x 1 station
Renal Ready Room – 1 station Nguiu,
Ramingining, Yirrkala, Kalkarindji, Mt
Liebig, Santa Teresa
Renal Ready Room – 2 station, Gove
Relocatable - 2 station, Galiwinku,
Maningrida, Milingimbi, Angurugu, Borroloola,
Amoonguna, Ti Tree, Ali Curung ,Oenpelli,
Ngukurr, Barunga, Lake Nash
Proposed new sites – Milingimbi,
Wadeye, Maningrida,
15
Peritoneal Dialysis Patients
TIWI
ISLANDS
GROOTE EYLANDT
CAPD
APD
Patients in TE = 28
Urban and rural Darwin, Katherine, Jabiru,
Timber Creek, Kalkarindji, Pigeon Hole,
Palumpa, Jilkminggan, Beswick, Ngukurr,
Gapuwiyak, Gove, Yirrkala, Milingimbi and
Maningrida
Patients in CA =10
Alice Springs x 6, Tennant Creek x 2, Kiwirrkurra
x 1, Santa Teresa x 1
16
Waste Management in Remote Areas

Remote community waste
directed to land fill

Each HHD patient generates
1 bin every 4-6 weeks.

Removal of biohazard waste

Tracking and management
resource intense

Biohazard waste
management legislation

Need a new management
strategy
17
Introduction of Turboburner
18
Turbo Burner Requirements

200L drum in reasonable condition to ensure a snug fit of
the turbo burner lid.

Weatherproof storage facility due to electrical components

Wood/cardboard/old oil or substitute combustible to
achieve the best burn

Requires the management (loading, lighting, storing) to be
allocated
19
After burn
20
Outcomes

Complete burn of medical waste with minimal accelerants
(waste oil or diesel)

Produced a smoke free and odourless burn

No hazardous gas emissions

A preferable option of disposing of dialysate waste to
landfill

A more cost effective option than removing waste from
communities
21
Turbo burner Locations
Yuendumu,
TIWI
ISLANDS
Ntaria
Kintore ,
Mt Leibig
Nguiu,
GROOTE EYLANDT
Wadeye
Santa Teresa
Galiwinku,
Maningrida,
Milingimbi,
Angurugu,
Borroloola,
Amoonguna,
Ali Curung ,
Ngukurr,
Barunga,
Lake Nash
22
Western Desert Nganampa Walytja Palyantjaku Tjutaku
(WNDWPT)






Reverse Respite Program – non-gov service delivery model
Supported through funding from sales of art and mining royalties
Supported by a board of elders from the Kintore region and a separate
board from Yuendumu (providing own funds, under the guidance of
WDNWPT)
Alice Springs location at the Purple house providing Social support,
advocacy, PHC services, self care training and respite dialysis
Nurse assisted dialysis and Return to Country trips provided:
 Kintore
 Yuendumu
 Hermannsburg
Nurses employed under a private contract arrangement
23
Requirements for Community Dialysis
NT Renal Services has a SLA with WDNWPT to support with machines
and chairs to provide reverse respite.
WDNWPT ensure clients:
 have clearance from the Nephrologist to be dialysed away from the
Renal unit
 trip is planned (ie you can’t turn up at your community dialysis facility
and expect to be dialysed)
 have family support for your visit
 have been going regularly to dialysis, taking meds to be considered for
a trip home
 Who miss scheduled dialysis out bush are returned to town
 WDNWPT is responsible for the dialysis care of the patient.
24
Renal Indigenous Resources
25
Renal Indigenous Resources
26
Mobile Bus Feasibility - Service Gap

Limited rural satellite units and limited placements




Self-care Therapies





Tiwi Dialysis Centre – fly in fly out basis, difficult to expand
Katherine Dialysis Unit – most from surrounding regions, issues of
relocation
Tennant Creek Dialysis Unit – at capacity
Home HD - growing but long training periods, self-reliance
important, infrastructure rollout slow and costly
Peritoneal Dialysis – uptake improving but ‘churn’ high
Resistance from community relating to poor perceptions of RRT
Disincentive of staffed facilities
Patient Personal Capacity


Many patients will never attain self-care status
Reliance on ‘partners’ – spectacularly unsuccessful
27
Opportunity for Improvement

Psychosocial

maintenance of relationships with kin and country,

Enable important events to be attended safely – community
business, funerals, festivals

Improved morbidity and mortality

Reduce acute care costs

medical evacuation events, decrease hospitalisations

Increase opportunities for education around renal disease

Opportunity to change community perceptions

Increase opportunities to attract and retain staff
28
Dialysis Bus Floor Plan
29
Comparison of Models - Capital
Requirements
Reverse Respite Model
- One community
Mobile Dialysis Service
- Multiple communities
2 station facility
$350K
$340K
Nurses Accommodation
$550K
included
Vehicle
$75K
included
Fencing/office Equipment
$20k
$5k
TOTAL
$995K
$345K
30
Pros and Cons of Mobile Service

Benefits







Can provide respite dialysis to a broad range of communities
Infrastructure and recurrent costs are lower
Can be utilised to provide education and undertake clinics
Is self-contained with minimal impact on community
Only requires access to water
High interest in service implementation (recruitment)
Risks




Robustness of dialysis machinery over un-graded roads untested
Continuous access to water maybe an issue
Will need time to work out teething problems
Space configuration for dialysis, sleeping and living yet to be
tested
31
32
33
34
35
Ali Curung Visit
36
37
38
THANK YOU
39