Evaluation of implementation of best practice models of care based on the updated Recommendation for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (PDF 1.3MB)
The Australian Medicare Local Alliance (AML Alliance) was funded to enhance the capacity of General Practitioners (GPs) and other primary health care providers to provide high quality treatment through best practice models of care for otitis media (OM) in Aboriginal and Torres Strait Islander children. The key strategy to achieve this was the dissemination and implementation of the Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations 2010, (the Guidelines) by Project Officers (POs) to clinicians and other health and allied health workers. The primary aims were to increase awareness of the Guidelines, improve service delivery for the prevention, early detection and management of OM and increase diagnosis and appropriate referral of children with OM aged 0-4 years.
The project was implemented from June 2012, for 12 months. Through an expression of interest process, eight eligible agencies were identified as suitable program sites and these comprised 31 individual services, including Aboriginal Medical Services (AMSs) and Private Medical Practices (PMPs). The agencies chosen were located in Western Australia, Victoria, New South Wales and Queensland and varied greatly in geographical layout as well as population characteristics and density, thus limiting the ability to draw direct comparisons between the locations. However, some important observations could be made within each pilot area.
Given the short time involved, the Guideline dissemination as well as education and health promotion activities carried out were effective. Primary screening of children 0-4years and older children across the sites was not consistent and accurate coverage and detection rates remain unknown. The uptake of the Guidelines by individual medical practitioners working from private practices was overall positive leading to some important changes in information systems that enhanced clinical care and management of OM. Such effective systems have implications for use by other services. The project did not result in any sustainable increases in access to Ear Nose and Throat medical specialist care or secondary audiology services, and such access remains to range from satisfactory to very poor across the sites. It was not possible to measure if there was increased effectiveness in management of OM referral pathways as a result of the dissemination of the Guidelines but it was apparent that where available, care-coordination roles improved referral and follow-up processes.
POs employed for this project were faced with many challenges. Twelve months proved to be a relatively short period of time for one part-time person, within each agency area, to recruit health services to participate, facilitate and promote education and training workshops, monitoring (if possible) of best practice initiatives and participate in community-based health promotion awareness raising and education activities. However, the work done by the POs plays a major role in informing more specific ways in which the detection and management of OM in very young Aboriginal and Torres Strait Islander children can improve. The ongoing dissemination of the Guidelines is important. There is also a need for regional coordination roles for effective implementation of primary screening of OM to promote more effective follow-up systems so children who fail primary screening receive a medical review and the care their condition requires. Increased access to hands on clinical training in the detection of OM is important. Care management roles, at the service level, are likely to enhance effective ongoing clinical management of OM in children. Greater participation by maternal and child health service providers is needed to address screening for OM in the very young age group. Such participation will increase the likelihood that best practice models of care, as suggested in the Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations 2010, are implemented.
In assessing the approaches, strategies and activities taken by agencies, none could be described as delivering a model of care according to accepted definitions. Some POs did strive to promote client-centred care but they were not in a position to impose this approach on health services participating in this pilot project. Many of the successful approaches and activities implemented by POs were tailored for local contexts and would sit comfortably within a collaborative model of care. The collaborative care model is sufficiently flexible to take account of local needs and contexts and includes that a client-centred approach to delivering care be adopted. Because of these factors this model is recommended as best able to meet the needs of disadvantaged Aboriginal and Torres Strait Islander children with OM.
Ten key points identified:
- Key Point 1: The needs identified by services to integrate Guideline use into their practices varied and it was important that services had the opportunity to identify their own specific needs.
- Key Point 2: It was clear to the evaluator that flexibility in planning the implementation of programs at the local level was essential and that no one plan would be suitable for all.
- Key Point 3: To achieve greater impact and have a sustained effect, education, training and awareness raising activities will need to be ongoing to take account of staff turnover, also to maintain good levels of awareness and knowledge among existing staff.
- Key Point 4: Ongoing practical training in clinical detection and management of OM is needed across the Agencies in order to meet the necessary demand and staff turnover issues.
- Key Point 5: The success in embedding the recommendations of the Guidelines into practice in many services was often the result of leadership from practice management and the motivation, initiative and energy and other personal qualities of the practice nurses (or equivalent) employed by each of the services.
- Key Point 6: Some carers of children with OM require empathetic support (including assistance to make appointments, reminders, travel assistance to attend appointments) to successfully navigate the OM referral pathway. Care co-ordination is available to children and adults with recognised chronic diseases such as diabetes. It would be appropriate that families who have children with other chronic health care needs, including OM, be eligible for this service.
- Key Point 7: In the presence of perceived carer apathy in meeting a child's OM care needs, it is appropriate that others are aware of this and are in a position to advocate for the child's greater wellbeing.
- Key Point 8: It appears that a non-service provider and independent driving force (such as provided by the Medicare Local POs) is necessary to facilitate and coordinate local education, promotion and awareness raising of OM.
- Key Point 9: The collaborative care model is seen as flexible and best able to meet the needs of disadvantaged Aboriginal and Torres Strait Islander children with OM. This model promotes that health service providers from different professions and agencies provide comprehensive services by working with people, their families, care providers, and communities to deliver the highest quality of care.
- Key Point 10: The National Advisory Council on Mental Health's report on Models of collaborative care for children and youth (0-25 Years) outlines a plan that could be adapted to develop a collaborative model of care for children with OM.
Two recommendations made:
- Recommendation 1: For future training needs, if feasible, it is recommended that a locally based audiologist or other specialist in the field be contracted to provide training (as opposed to a visiting provider).
- Recommendation 2: In the future, consideration should be given to having two levels of training. i.e. one for those who diagnose and medically manage children with OM and another less complex for those who do opportunistic screening. The objective of the latter training is that the health professional identify if an ear appears healthy or not (pass/fail). Children who fail are then referred for medical review. This takes any pressure off the health professional to correctly diagnose the condition of the ear.
Page updated 2013-11-19