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ACT Breathlessness Intervention Service
People with lung and heart conditions live with breathlessness every day and experience anxiety, depression, and social isolation. Chronic breathlessness is a frequent reason for Emergency Department visits and hospital admissions.
Internationally, growing research supports the use of symptom-based care to lessen the effects of breathlessness to improve quality of life, assist families/carers in distress and potentially reduce hospital admissions. Despite the research, there are few available services in Australia, including the ACT, that focus on the management of breathlessness.
CHN is working in collaboration with University of Technology Sydney (UTS), Southside Physio, consumers and clinicians to co-design and develop a pilot of a home Breathlessness Intervention Service tailored to the ACT. UTS will complete an independent evaluation of the pilot.
The 12-month ABIS Pilot program opened referrals from general practice in March 2023. The client receives an initial home visit by a Physiotherapist, with 2 to 4 follow-up visits at home or via a phone call by a Nurse or a Physiotherapist. Interventions are non-pharmacological and address the ‘Breathing, Thinking and Functioning’ components of breathlessness. Interventions are aimed at both patient and/or their carer.
Contact: palliativecare@chnact.org.au
Social Workers in General Practice Pilot Program
CHN’s Needs Assessment identified the lack of support for people with complex social and health needs as a significant barrier to people accessing and navigating appropriate services.
As a first in Australia, the Social Workers in General Practice Pilot Program aims to address some of these barriers, often caused by the social determinants of health. CHN funded four general practices in the ACT to participate in the pilot, commencing in July 2022, with Social Workers as an integrated part of their general practice team. CHN is the first PHN to initiate such a pilot.
Social Workers have been engaged in a range of activities involving direct patient support, including counselling, navigating complex health care systems and processes, and providing education to practice staff and patients on the scope of Social Workers within the general practice environment.
Social Workers are supported by funded professional clinical supervision and a community of practice. In addition, each practice has a funded nominated GP champion allocated for the pilot program.
University of Canberra has commenced an independent evaluation of the pilot program. CHN presented early findings from the practices in September 2023. View the poster here
In November 2023, it was announced that the pilot has been extended for another 15 months, until March 2025. The Social Workers in General Practice Pilot Program is supported by funding from the ACT PHN through the Australian Government’s PHN Program.
Pharmacists in Residential Aged Care Facilities trial
Over 95% of residents living in residential aged care facilities (RACF) have experienced medication-related problems. To combat this, CHN commissioned the University of Canberra (UC) to undertake a trial embedding pharmacists into RACFs. Phase one consisted of a randomised controlled trial where Pharmacists were employed to be on-site part-time to conduct medication management and phase two involved a Pharmacist on-site for all control RACFs involved in phase 1.
As a first in Australia, the Pharmacists in Residential Aged Care Facilities trial aimed to reduce inappropriate medications, medication-related adverse effects, and hospitalisations, as well as improve quality use of medicines indicators such as reducing use of chemical restraints.
The Pharmacists worked collaboratively with the facilities care teams, other prescribers, allied health professionals, community and hospital pharmacists, alongside the resident and their family. CHN commissioned UC to undertake an independent evaluation, which was launched in February 2023. Multiple stakeholders were consulted as part of the evaluation to share insights and learnings of embedding pharmacists in the RACFs. The trial showed that having an on-site Pharmacist resulted in a reduction in residents taking potentially inappropriate medicines.
The independent evaluation demonstrated that having a Pharmacist on-site at a RACF assisted in:
- a decrease in the proportion of residents taking potentially inappropriate medicines
- a decrease in anticholinergic drug burden, which is associated with cognitive decline, delirium and increased risk of falls
- a decrease in the usage and dosage of antipsychotic medicines prescribed for residents
- establishing positive collaborative working relationships between on-site pharmacists, GPs and other prescribers (nurse practitioners, geriatricians, and other specialists), allied health professionals, and community and hospital pharmacists), RACFs managers, staff, residents and family members