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Developed in partnership with GPs, a new telehealth model of care using remote monitoring, known as telemonitoring (TM), was introduced in South Western Sydney (SWS) in 2015, transmitting clinical readings taken at home to telehealth coordinators. This study explored the experiences, beliefs and attitudes of general practice staff to identify barriers to and facilitators of the SWS TM model. Responses were collected from a purposive sample of 10 participants via semistructured interviews (n = 9 interview sessions) and the resulting transcripts were analysed thematically. Four themes were identified: lack of understanding and involvement; patient-centred care and empowerment; clinical practice and process factors; and system-wide communication and collaboration. Participants recognised some actual and potential benefits of TM, but barriers to TM were identified across all themes. Feedback provided by participants has informed the ongoing formulation of a more ‘GP-led’ model of TM.

Objective: This study aimed to develop an understanding of the implementation of the Leading Better Value Care (LBVC) initiatives at a Local Health District (LHD). Methods: The study used a mixed method including literature reviews, survey and semi-structured interviews of the stakeholders who participated in the implementation of the state-wide LBVC program within a LHD. All information used in this study was de-identified and anonymous. Results: Twenty-two stakeholders responded to the survey reviewing the implementation process. Fifty-one percent of the participants reported that there was very good sharing of information and ideas within the LHD, where clinicians were provided with data to support better decision making (77%). The stakeholders were overall moderately to very satisfied (60%) with how the program was implemented within the LHD. A total of 10 interviews were conducted. Analysis of the transcripts identified four core themes linking different aspects of the implementation of the LBVC initiatives: 1) Engagement; 2) Understanding of implementation process; 3) Challenges; and, 4) Future strategies for implementation. This local learning will provide valuable information to develop strategies so as to improve the LBVC program and support the LHD in continuing to embed, scale and sustain the initiatives. Conclusion: This study has provided the experience of the stakeholders participating in the implementation of the LBVC program and how it was being implemented across the LHD. It has identified factors which contribute to improvement of future implementation of similar programs.

PurposeThis study has demonstrated how technology may contribute to integrated care solutions by comparing conventional ward telemetry (WT) to a wearable ECG monitor (S-Patch) to detect atrial fibrillation (AF) in patients with stroke.Design/methodology/approach51 patients admitted for stroke workup were recruited across two major tertiary centres to compare WT monitoring for two days versus S-Patch for four days in the detection of AF. The efficacy to detect AF using both technologies was assessed via data extractions and medical officer review. A matrix was used to measure nursing/patient satisfaction and setup/resource times were assessed.FindingsPatients (84–94%) and nursing staff (75–95%) preferred the S-Patch wearable technology. Non-parametric tests indicated significant time saving for removal of S-Patch versus WT [2.2 min vs 5.1 min (p = 0.00)]. Efficacy of S-Patch to detect AF following medical officer review was greater than WT, with seven patients identified with AF by S-Patch versus one using WT. The S-patch had a false positive rate of 78%.Research limitations/implicationsThe S-Patch is sensitive in the detection of AF; however, it showed a high false-positive rate with automated reporting. This study has provided insight into the details of delivery of integrated healthcare using wearable technology.Originality/valueThe technology and partnership were the first-in-kind in Australia. The S-Patch had a higher detection rate of AF compared to WT which allows patients to be anti-coagulated appropriately for the prevention of further stroke. The results of this study will be ideally placed to inform future policy in integrated healthcare using new technologies.

Background Although primary care is a well suited context for conducting advance care planning (ACP), there are many barriers to initiating discussions regarding future health preference and end-of-life conversations. Methods This qualitative study conducted 30 detailed individual interviews with senior administrators, medical and nurse practitioners of a local health district, NSW Ambulance, e-Health NSW, general practitioners and practice nurses to find out about barriers to ACP in South Western Sydney. Results Thematic analysis was conducted on the interviews. Six major themes were identified: Prevalence; Empowerment of roles and responsibilities; Lack of training/knowledge/confidence; Fragmentation of care; Patient/family readiness; and Prognostication. Half of the participants were willing to use a prognostic tool to identify when a patient was likely to be at the end of their life and provide a prompt to initiate ACP. Conclusion In addition to addressing training and acknowledging resource constraints, these findings suggest that if a prognostic tool was validated and practical in a primary care setting, it may provide valuable assistance to encourage everyone in society to begin discussing this issue and completing ACP.

Dr Helen Hurst and colleagues introduce the work of the International Society for Peritoneal Dialysis Nurse Liaison Committee, discussing international collaborations aimed at improving outcomes for patients on peritoneal dialysis and some key areas of work.

Purpose A recent study on the implementation of telemonitoring has provided an opportunity to explore how telemonitoring could be further developed to enhance better patient, carer and clinician experiences for patients living with chronic disease. The purpose of this paper is to identify the challenges and lessons of the telemonitoring implementation and to identify strategies to inform future implementation. Design/methodology/approach A qualitative study was conducted with a purposive sample using semi-structured interviews to explore their views about the issues identified in the research aims. Interview themes were informed by current literature and the findings from local studies. Interviews were recorded, transcribed verbatim and analyzed thematically. Findings A total of 16 participants were interviewed. Overall the recruitment of 56 percent were from identified potential participants. Five core themes were identified, linking different aspects of the telemonitoring implementation: impact of telemonitoring; implementation and management lessons; program risks; program main changes from beginning; and future strategies and recommendations. Originality/value This study will inform the wider roll out of telemonitoring across the region with the goal of ensuring future interventions achieve better clinical outcomes, patient, carer experience and deliver better value.

Purpose The purpose of this paper is to appraise the development, implementation and acceptance of HealthPathways (HP), specifically in Type 2 Diabetes Mellitus (T2DM), at different levels of the health system in a large metropolitan Local Health District in Australia. Design/methodology/approach This study used a programmatic approach and mixed methods including literature reviews, site visits, semi-structured interviews of stakeholders and General Practitioners (GPs), and surveys (GPs and patients) to better understand the development, implementation and acceptance of T2DM pathways. Findings Results from this study indicate that 63 percent (n=37) of all survey respondents use HP and nearly half (47 percent) use HP in caring for a patient with diabetes. More than 80 percent of the health professionals found HP a useful tool, which has improved the quality of care, keeps them informed and supports diagnostics process. The use of website has led to an improvement in referral quality (69 percent), has assisted in the provision of more healthcare in the community (87 percent) and made their job easier. Thematic analysis from stakeholder interviews (n=12) emphasizes the importance of established collaborations and the need for standardized tools with common priorities and transparency in processes. Practical implications This study has provided insight into the details of delivery of integrated healthcare using HP. It provides a preliminary analysis of the lessons learnt for the implementation of HP. Originality/value The results of this study will be ideally placed to inform future policy amendments in the area of integrated healthcare as well as serving as a guide on implementing HP in the future.

Made available in DSpace on 2021-06-25T10:28:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-01-01 Background: Peritoneal dialysis (PD) technique survival is an important outcome for patients, caregivers and health professionals, however, the definition and measures used for technique survival vary. We aimed to assess the scope and consistency of definitions and measures used for technique survival in studies of patients receiving PD. Method: MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled studies (RCTs) conducted in patients receiving PD reporting technique survival as an outcome between database inception and December 2019. The definition and measures used were extracted and independently assessed by two reviewers. Results: We included 25 RCTs with a total of 3645 participants (41–371 per trial) and follow up ranging from 6 weeks to 4 years. Terminology used included ‘technique survival’ (10 studies), ‘transfer to haemodialysis (HD)’ (8 studies) and ‘technique failure’ (7 studies) with 17 different definitions. In seven studies, it was unclear whether the definition included transfer to HD, death or transplantation and eight studies reported ‘transfer to HD’ without further definition regarding duration or other events. Of those remaining, five studies included death in their definition of a technique event, whereas death was censored in the other five. The duration of HD necessary to qualify as an event was reported in only four (16%) studies. Of the 14 studies reporting causes of an event, all used a different list of causes. Conclusion: There is substantial heterogeneity in how PD technique survival is defined and measured, likely contributing to considerable variability in reported rates. Standardised measures for reporting technique survival in PD studies are required to improve comparability. School of Medicine Keele University Department of Nephrology Princess Alexandra Hospital Australasian Kidney Studies Network The University of Queensland Translational Research Institute Department of Renal Medicine Auckland City Hospital Polycystic Kidney Disease International Polycystic Kidney Disease Charity Department of Medicine The University of Hong Kong Queen Mary Hospital Department of Medicine Western University Botucatu School of Medicine University of Sao Paulo State—UNESP Clinical Innovation and Business Unit South Western Sydney Local Health District Faculty of Nursing University of Sydney UNSW Faculty of Medicine University of New South Wales School of Health Science University of Tasmania Maisonneuve-Rosemont Research Centre and Hospital The Kidney and Transplant Practice Mount Elizabeth Novena Hospital Medical School University of Western Australia Sydney School of Public Health University of Sydney and Centre for Kidney Research The Children’s Hospital at Westmead Division of Nephrology St Michael’s Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute St Michael’s Hospital University of Toronto Botucatu School of Medicine University of Sao Paulo State—UNESP

Introduction: HealthPathways (HPW) is an online health information portal which provides General Practitioners (GPs), guidance on the assessment, management, and referral of a range of conditions linked to local resources. It has been adopted as an aid to improve the integration of patient care across the health system. However, there is a lack of understanding of the acceptance of pathways within primary health. Theory/Methods This qualitative study identified baseline factors that promote the successful implementation of HPW in a major Local Health District (LHD) in Australia. The development, implementation and acceptance of Diabetes HPW was evaluated using semi-structured interviews with purposive samples. Interviews were digitally recorded, transcribed, and analysed qualitatively using a thematic analysis approach. Results A total of 16 interview transcripts were analysed. Four core themes were identified in relation to the processing of implementing the HPW: 1. The importance of creating & maintaining collaborative partnerships through the development of the pathways (engagement); 2. the process promoted trust and understanding between organisations and made their individual aims, processes and values clearer to one another (transparency); 3. HPW implementation was also seen as means of committing individual organisations to provide standardised and consistent care across the Local Health District (accountability); and, 4. the importance of providing adequate funding and resources to support the ongoing development and revision of HPW (Sustainability). Discussions This process evaluation provides additional, qualitative evidence about what facilitates the successful implementation of HPW and identifies barriers that hinder its success. Researchers anticipated the interview protocol would elicit an overall discussion about the strengths and limitations of HPW, as opposed to only about the Type 2 DM pathways; in particular its usability and utility, and suggested improvements or factors that might contribute to its success. An inductive approach was employed to conduct an analysis that extracted common themes amongst the qualitative data. Conclusions: This study provides an insight into the development and implementation of Type 2 Diabetes Mellites HPW across different levels of the health system in the LHD. The feedback and experiences from implementation and utilisation of the HPW across different levels of the health system and program implementation, provides the GP with an overall informed perspective on the acceptability of the pathways, what the general consensus is on its applicability and a transparent view on the impacts that the HPW may have on its day-to-day use. Lessons learned Collaboration between individuals and organisations has strengthened the development and implementation of the HPW. Engagement and transparency have demonstrated the significance of establishing collaborative partnerships to implement HPW. Limitations Despite a number of strategies to encourage the participation of GPs, the recruitment of GPs to take part in interviews was a challenge for the research team. Suggestions for future research Further research would be useful to investigate and explore the health outcomes and impact of HPW on the community including broader scope for evaluation of multiple pathways to identify the best ways of ensuring sustainability and uptake of the program.

Background:There is substantial variation in peritonitis rates across peritoneal dialysis (PD) units globally. This may, in part, be related to the wide variability in the content and delivery of training for PD nurse trainers and patients.Aim:The aim of this study was to test the feasibility of implementing the Targeted Education ApproaCH to improve Peritoneal Dialysis Outcomes (TEACH-PD) curriculum in real clinical practice settings.Methods:This study used mixed methods including questionnaires and semi-structured interviews (pretraining and post-training) with nurse trainers and patients to test the acceptability and usability of the PD training modules implemented in two PD units over 6 months. Quantitative data from the questionnaires were analysed descriptively. Interviews were analysed using thematic analysis.Results:Ten PD trainers and 14 incident PD patients were included. Mean training duration to complete the modules were 10.9 h (range 6–17) and 24.9 h (range 15–35), for PD trainers and patients, respectively. None of the PD patients experienced PD-related complications at 30 days follow-up. Three (21%) patients were transferred to haemodialysis due to non-PD–related complications. Ten trainers and 14 PD patients participated in the interviews. Four themes were identified including use of adult learning principles (trainers), comprehension of online modules (trainers), time to complete the modules (trainers) and patient usability of the manuals (patient).Conclusion:This TEACH-PD study has demonstrated feasibility of implementation in a real clinical setting. The outcomes of this study have informed refinement of the TEACH-PD modules prior to rigorous evaluation of its efficacy and cost-effectiveness in a large-scale study.

Purpose The purpose of this paper is to analyse early findings from telemonitoring data for chronic obstructive pulmonary disease patients, residing in Wollondilly Shire, New South Wales, Australia. The Shire has 19 small scattered and isolated rural communities, which experience undersupply of healthcare providers. Findings are to be used for further research to support wider implementation of telemonitoring by general practitioners (GPs). Design/methodology/approach Local patients with multiple chronic obstructive pulmonary disease hospital admissions were allocated home telemonitoring equipment, entering readings according to their GP management plan. Demographic, biometric and self-assessment readings were retrospectively collected, from July 2015 to April 2016. Findings Data for 18 patients aged 44-87, with equal gender representation was analysed. There was a total of 24,545 data points from 2,932 readings. Over half showed high clinical risk; 93 occasions required GP escalation, 23 per cent for respiratory conditions, in 14 patients. Nine were hospitalised, 51 per cent for respiratory conditions. Practical implications Home telemonitoring of chronic obstructive pulmonary disease was found to be a promising patient management approach, providing accurate, reliable health indicators. Its use empowered patients to improve symptom control and health outcomes. Originality/value Experience in Australian general practice with telemonitoring is limited. High protocol compliance occurred, risk indicators were obtained and the value of home telemonitoring was confirmed.

Introduction Up to a 10-fold difference in clinical outcomes between Australian peritoneal dialysis (PD) units exists. There is an international focus on the harmonisation of educational practices in PD to determine whether this may lead to improved patient outcomes. Aims Evaluate the current teaching practices of nurses and patients in Australian PD units. Methods An online survey with questions on nurse and patient training was made available to PD units in Australia. Results Thirty-eight (70%) of 54 PD units in Australia completed the survey. A written standardised curricula was utilised in 21 units (55%) for nursing staff and 30 units (86%) for patients, with 22% and 12% including an electronic delivery component for each group respectively. Universal teaching of adult learning principles was not demonstrated. The hours spent on teaching nursing staff ranged from 100 hours in 21% of units. The average number of hours spent by nurses each day to train patients ranged from 6 hours in 11% of units, with the average total training days ranging from 2-3 days in 14% to over 7 days in 14% of units. Staff and patient competency assessments were performed routinely in 37% and 74% of units respectively. Conclusions Considerable differences exist amongst Australian PD units in the education of staff and patients. There is a general lack of delivery and competency assessment to meet educational standards. It remains to be seen if harmonisation of educational curricula can translate to improved clinical outcomes. This article is protected by copyright. All rights reserved.

Key Clinical Message Younger adults considering home dialysis need support to ensure home circumstances are suitable and affordable. Home circumstances relate closely to the financial burden reported by younger home dialysis users. Attention to home circumstances of younger patients with chronic kidney disease by policymakers, funders, and healthcare practitioners is needed.

SUMMARYBackground International guidelines recommend treatment of anaemia due to chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs). Objective To document the time required and the cost in terms of nursing time to prepare and administer ESAs to patients on facility based haemodialysis (HD) with anaemia due to CKD before and after the introduction of long-acting ESAs. Design A time and motion study was implemented at four HD units in Australia to determine the time and costs associated with preparing and administering ESAs before and after the introduction of long-acting ESAs. Participants This was a prospective, observational study of workplace practices at four HD units in Australia. Measurements Outcome data included the time taken to prepare, and administer ESAs. Results The time costs of preparation and administration per patient per year had a wide variability within each unit and ranged from Australian AUD$55.75 (38 euros) to AUD$90.49 (62 euros) before the introduction of long-acting ESAs. This dropped by 73–80% following the introduction of long-acting ESAs, representing an annual cost savings of between AUD$2,591 and AUD$5,914 if all patients on HD were switched to a long acting ESA. Conclusion Switching from a short-acting to a long-acting ESA in HD units leads to a significant reduction in time costs of health professionals in preparation and administration of ESAs by up to 80%. Practical application: This time and motion study has added further evidence on reduction of human effort by taking advantages of new research development, such as the long acting ESAs.

Introduction: Telemonitoring of patients with chronic diseases shows potential for improved quality of community based care resulting in fewer hospital admissions. Questions remain about how best to employ the technology, staff roles and how to integrate the intervention into existing healthcare practice and community based care. A previous retrospective analysis of telemonitoring study within South Western Sydney indicated the need to understand in more detail how the program was being implemented Theory/Methods: The aim of the study is to identify the challenges and lessons of the telemonitoring implementation in the District, and identify strategies to inform the future implementation of telemonitoring initiatives. A program logic model was developed in order to develop an array of themes for interviews. Semi-structured interviews were carried out with a purposive diverse sample. It consisted of managers, administrators and clinicians involved in implementing telemonitoring, as well as those from the private telemonitoring services provider. Interviews were recorded, transcribed verbatim and thematic analysed. Results: Sixteen semi-structured interviews were conducted (response rate-55%). Analysis of the transcripts identified 5 core themes linking different aspects of the implementation of the telemonitoring program: 1) Impact of telemonitoring (in community and health systems); 2) Implementation and management lessons; 3) Program risks; 4) Program main changes from beginning; and, 5) Future strategies and recommendations. The challenges from implementation were also included. The participants viewed telemonitoring as a “Positive” initiative that had contributed in providing self-management capability for the patients, as they had increased ownership of their health and confidence in managing their own care. Stakeholders reported that telemonitoring was embraced enthusiastically by many patients and staff, and that it had a positive impact. They reported that patients credited it as a tool that provided support and increased their confidence in managing their own disease at home. The identified main challenges in implementing the telemonitoring model of care are: connectivity/network issues, up-to-date technology and software, limited resources (i.e. consumables, staff, number of devices), and potential for dependency on equipment. Future strategies to improve such initiative could be managing such programs in house, organizing more human resources, more promotion and education around available programs at community level and within the hospital systems, making it better structured, engaging culturally and linguistically diverse (CALD) communities, and incorporating research and evaluation component. Discussions and conclusion: This study provides guidance for the future development and escalation of telemonitoring across NSW. It highlights the importance of partnerships between the District Health, PHN, service providers (private/non-private) and local general practitioners. The results of this study will contribute to the understanding of practical considerations as well as barriers and facilitators of implementation telemonitoring beyond this region. Lessons learned: Selection of right cohort for the intervention and a better communication between the patients, staff and the GPs. Limitations: Only one service provider. Suggestions for future research: To explore the feasibility related to self-management aspects of telemonitoring in a cohort of patients with early stages of chronic diseases and primary health professionals views on acceptability and perceived usefulness of telemonitoring in care provision.

Introduction Home dialysis has not only been shown to improve outcomes and quality of life for people with Chronic Kidney Disease, it also results in better use of healthcare resources. The successful resurgence of Peritoneal Dialysis (PD) is driven by a clear understanding of the structure of the PD team, patient and staff education, resources available and a business plan. Context and objective In August 2009, the HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies inclusive of PD. Through a directed process of reflection and analysis of strengths, weaknesses and opportunities, the HOME Network has refined its vision and mission to identify solutions and strategies to promote and enhance home dialysis. Members are committed to driving outcomes aligned with the group’s renewed strategy and working towards achieving their overall vision and mission statement. This paper will discuss the key strategic direction and outcomes achieved through the HOME Network. Targeted population The HOME Network included volunteer members of nurses, allied health and consumers. Highlights The following are the key elements for success: 1. Selection of membership 2. Establishing the HOME Network’s identity 3. Selection of appropriate projects and determine timelines 4. Align and consult with stakeholders 5. Preparation of bi-annual workshop 6. Financial management and sustainability 7. Leadership 8. Collaboration with and dual membership of committees with similar goals 9. On-going evaluation Over 30 projects have been completed to date under the following focus areas and over $3.5Million of funding for projects and research studies in the area of: • Improved awareness, knowledge and training about home dialysis for healthcare professionals. • Early and ongoing education for patients about home dialysis as part of a standard model of care. This includes greater awareness and implementation of early and ongoing education for Australians with CKD. • Support for new initiatives and technologies that strengthen home dialysis utilisation as part of establishing flexible and innovative models of care that strengthen support for people on home dialysis including their carers. Major milestones have been achieved. Like most great deeds, the success of the HOME Network requires knowledge, meticulous planning, capital investment, confidence and commitment of the nephrological team. Transferability The model of the HOME Network can be easily transferred to other professional bodies nationally and internationally. Conclusions The experience at the HOME Network presented here highlights the importance of a vision and thorough stakeholder engagement by senior clinicians who are passionate about home therapies.

Introduction: According to 2014-15 National Health Survey, 1 in every 2 Australians (50%) have at least one prominent chronic condition. Telehealth is gaining recognition as key link in the delivery of health care services. Telemonitoring of patients with chronic conditions shows promise for early detection of deterioration and intervention to reduce emergency visits and hospitalisations. Practice change: In 2015, a new model of care using telehealth developed in partnership with General Practitioners (GP) allowing regular clinical readings at home to transmit to a telehealth coordinator, has offered benefits in terms of quicker access to patient information and less time spent performing home visits, while still maintaining that crucial ‘face-to-face’ contact. Aim and theory of change: This program applied the ‘Benefits Realisation’ approach to confirm current service gaps, identifying potential solutions and implementing the changes. This included the co design with the GP, the PHN and the consumers, reviewing the referral pathways, triage processes, geographic location of the patients, technology required and model of care. Targeted population: The telemonitoring project was developed for a regional area community with high rates of chronic disease hospitalisations and sub-optimal access to healthcare. Timeline: The telemonitoring initiatives commenced in 2015 and have been sustained. Highlights: This program was implemented in stages with initial phase adopted by 7 GP practices (Total of 8 GP Practices in the region). With the roll-out to 5 more local government areas (>100 practices). This reflects the ongoing commitment, sense of clinical ownership and strong relationship between GPs, private providers and stakeholders. Patient compliance in terms of taking required readings as predetermined in GP care plans, was very high with only 8% of missed readings, demonstrating the willingness of patients to be involved in their own care. The results from the interview indicate the benefits from telemonitoring which are greater at an earlier stage of chronic diseases. This provides patients and carers opportunity to better understand their condition and, in turn, enables patients to better self-manage. It empowers patients to take an active part in their own health, improving self-management and reducing dependency on traditional reactive service delivery models, at a lower cost and with improved patient outcomes. Sustainability and Transferability: Since 2015, the initiative has transitioned to become part of the Local Health District Integrated Care for People with Chronic Conditions (ICPCC) program and is now sustained within an ongoing service delivery model and has commenced roll-out to other Local Government Areas. The target patient group has also expanded to include other chronic conditions. Conclusions: This model of telemonitoring provides a patient focused approach with the GP as key stakeholder for clinical governance and integration across different sectors of the health system, together with enhanced patient and carer experience as partners. Discussions: The project explores innovative ways to promote greater partnerships amongst LHD, PHN, GPs, patients and private providers, linking care between hospitals (acute care), primary and community services to improve patients’ self-management capability. Lessons learned: Selecting the right patients for telemonitoring and potential for self-management.

Introduction: The suburb of Oran Park in south west Sydney is undergoing rapid housing development, population increase and demographic change which in turn, drives major changes in the area’s population characteristics, their health service needs, and provides an opportunity to strategically evaluate and address those needs. Practice Change: The establishment of the Oran Park Family Health (OPFH) Integrated Primary Care Centre (IPCC) seeks to provide multidisciplinary, evidence-based and patient centred healthcare at primary care level. It is a unique partnership between the Local Health District , Primary Health Network, University and private practice stakeholders. Aim and theory of change: The primary aim of OPFH is to provide relevant and effective primary and integrated care services to the locality as an alternative to and prevention of the use of hospital services. Its evaluation adopts an in-depth case study approach, collecting quantitative and qualitative data to determine whether the establishment of OPFH is associated with change in the use of hospital services and what may be the underlying causative factors. Population and Stakeholders: The service needs of the catchment will be driven by resident population growth with its associated socio-economic and epidemiological characteristics, and will be monitored via the evaluation arm of the project. Timeline: Started in 2017 – prospective long-term Highlights: The OPFH baseline evaluation has been completed: • Semi-structured interviews – clients (Group 1) and stakeholders & clinicians (Group 2) • Practice records – define patient population, service use patterns and health needs. Group 1 Perspectives (n=20) Age range of 24-70 years (median = 38). Patient awareness of service integration was low, although they reported that clinicians and support staff work well as a team. Key themes identified: 1) ability of OPFH to meet patient demand; 2) need for additional services; and 3) desire for continuity of care with their preferred GP. Group 2 Perspectives (n=13) The group’s shortlist of priority service needs at OPFH has some overlap with patients’ service requests such as imaging, paediatrics/child health, physiotherapy, and mental health. Sustainability: Outcomes from the evaluation are fed-back to the OPFH and IPCC governance to address any program development changes so as to tailor the delivery of services to the population needs. Transferability: The learning of this initiative can be easily transfer to other Local Health District. Discussion: This initial stage of evaluation indicates that while patients are not highly aware of the integrated model that underpins delivery of care at OPFH, they see the need for a greater volume and variety of services at the centre to serve the rapidly growing, predominantly young population. Stakeholder feedback also highlighted the need for a variety of services at OPFH, although the specific services prioritised by each group differed substantially. Lessons: In future stages interview data will be obtained from external providers referring clients to OPFH (Group 3) and practice data linkage with Hospital/District records will allow patients’ use of primary care and hospital services.

Objective Treating depression among patients with chronic kidney disease (CKD) is imperative because of its high prevalence and health-related costs. However, many patients with CKD experience significant barriers to effective face-to-face psychological treatments. Internet-delivered cognitive behaviour therapy (iCBT) may help overcome the treatment barriers. The aim of the present study was to explore the acceptability and preliminary efficacy of iCBT for depression and anxiety among patients with CKD on haemodialysis. Methods A single-group open trial design involving 22 patients on dialysis and an established iCBT treatment for anxiety and depression was employed. The primary outcomes were symptoms of depression, anxiety and general psychological distress. The secondary and tertiary outcomes were disability, quality of life, kidney disease-related loss and kidney disease burden. A generalised estimation equation modelling technique was employed. Results Clinically significant improvements (avg. % of improvement) were observed in the primary outcomes of depression (34%), anxiety (31%) and general distress (26%), which were maintained or further improved to 3-month follow-up. Improvements were also observed for quality of life (12%) and kidney disease-related loss (30%). However, no improvements in disability and kidney disease burden were found. High levels of acceptability were reported and relatively little clinician time (99.45 min; SD = 14.61) was needed to provide the treatment. Conclusion The present results provide encouraging support for the potential of iCBT as an innovative way of increasing access to effective psychological treatment for CKD patients. These results provide much needed support for further research in this area. Trial registration: Australian and New Zealand Clinical Trials Registry: ACTRN12613000103763.

Background: An ageing population and geographical growth, along with an increase in the number of people that reside in specific location, are increasing the demand for renal replacement therapies. Hospital-based haemodialysis units are struggling to cope with the associated physical, staffing and cost demands. Home-based dialysis therapies are known to be more cost effective with superior social, physical health and survival outcomes. Methods: ‘RENEW, a renal redesign project, examined the pre-dialysis health care experience of renal patients to find opportunities to improve patient care outcomes and increase the uptake of home-based dialysis therapies. This article details two crucial parts of the approach to change management: (i) diagnostics—an inclusive, client focused, multidisciplinary approach to identify issues relating to the pre-dialysis journey—and (ii) solution design—an inclusive problem-solving approach to identify and marry solutions to the issues identified during diagnostics. Results: Based on feedback from patients/caregivers and staff interviews, utilizing a clinical redesign methodology, a new model of care was developed, implemented and subsequently embedded into clinical practice. The results have been evident via improved care coordination, enhanced patient preparation for dialysis, improved patient psychosocial welfare and, importantly, an increased number of patients planned for and commencing home dialysis. This has empowered patients by giving them the confidence, knowledge and skills to be actively engaged in their own care. The project resulted in significant expenditure avoidance. Conclusion: Change management strategies with successful implementation are vital components of evolving clinical practice to achieve both clinical and organizational goals.

Cardiovascular disease is more common in patients with chronic kidney disease (CKD), and traditional risk factors do not adequately predict those at risk for cardiovascular (CV) events. Recent evidence suggests elevated trimethylamine N-oxide (TMAO), created by gut microflora from dietary L-carnitine and choline, is associated with CV events. We investigated the relationship of TMAO levels in patients with stages 3b and 4 CKD to ischemic CV events using the CanPREDDICT cohort, a Canada-wide observational study with prospective 3-year follow-up of adjudicated CV events. Baseline samples were obtained for 2529 CKD patients. TMAO, choline, and L-carnitine levels were measured using tandem mass spectrometry. Baseline median TMAO level was high for the whole cohort (20.41 μM; interquartile range [IQR]: 12.82–32.70 μM). TMAO was independently associated with CV events (hazard ratio 1.23; 95% confidence interval: 1.06–1.42 / 1 SD lnTMAO) after adjusting for all potential CV risk factors. Those in the highest TMAO quartile had significantly higher risk of CV events (adjusted hazard ratio 1.59; 95% confidence interval: 1.04–2.43; P = 0.0351) in the analysis of recurring ischemic events. Among those with stage 3b CKD (hazard ratio 1.45; 95% confidence interval: 1.12–1.87 / 1 SD lnTMAO), independent of kidney function, TMAO levels identified those at highest risk for events. Our results suggest that TMAO may represent a new potentially modifiable CV risk factor for CKD patients. Further studies are needed to determine sources of variability and if lowering of TMAO reduces CV risk in CKD.

Key Clinical Message The longevity of a successful vascular access (VA) is enhanced when the care of the patient's VA is the responsibility of everyone involved, including the patient and their family. A family nursing perspective enhances VA care outcomes and increases quality of life and well-being for patients requiring hemodialysis.

Background Peritoneal dialysis (PD) is a home-based therapy where nurses train patients in its use. There has been no published randomized controlled trial (RCT) evaluating any specific protocol for nurses delivering PD training. A standardized education package based upon the best available evidence and utilizing modern educational practices may lead to improved patient outcomes. The aim is to develop a standardized, evidence-based curriculum for PD trainers and patients aligned with guidelines from the International Society for Peritoneal Dialysis (ISPD), using best practice pedagogy. Methods A literature search and clinical audit were conducted to identify current practice patterns and best practice. Results were reviewed by a focus group of practitioners comprising PD nurses, nephrologists, consumers, a medical education expert, and an eLearning expert. From this, a training curriculum and modules were developed. Results A comprehensive PD training curriculum has been developed, which includes modules for training PD nurses (trainers) and patient training manuals. The package comprises 2 introductory modules and 2 clinical case modules. The curriculum is designed for both interactive digital media (trainers) and traditional paper-based teaching with practical demonstrations (patients). Assessment is also addressed. Conclusion The need for the development of a comprehensive and standardized curriculum for PD nurse trainers and their patients was confirmed. This paper outlines the process of the development of this curriculum. Pilot testing of the modules was launched in late 2017 to examine feasibility, and planning has commenced for a RCT in 2019 to investigate the effect of the modules on clinical outcomes, and their wider application across Australia and New Zealand.

Introduction: In 2014, a health needs assessment conducted between a Local Health District (LHD), a local government council and a Primary Health Network showed a Chronic Obstruction Pulmonary Disease (COPD) hospitalisation rate of 105, higher than NSW benchmark (100), along with sub-optimal access to health services. Practice Change: In 2015, a new model of care via telehealth developed in partnership with General Practitioners (GP) allowing regular clinical readings at home to transmit to a telehealth coordinator, has offered benefits in terms of quicker access to patient information and less time spent performing home visits, while still maintaining that crucial ‘face-to-face’ contact. Aim / Theory: Promote wider collaboration between hospital, GP and private provider to improve a seamless and rapid access to care and coordination for the community, using telehealth technology. This proactive approach to chronic disease management will improve patient self-management capabilities, understanding of their condition and reduce presentations to Emergency Department (ED), through early recognition and intervention utilising telemonitoring in consultation with treating GP. Population: The telemonitoring project was developed for a regional area community with high rates of chronic disease hospitalisations and sub-optimal access to healthcare. Timeline: After identifying the priorities for the region through the 2014 health needs assessment, the telemonitoring initiatives commenced in 2015 and have been sustained. Highlights: Outcomes included: 1- Wider collaboration with 90% of the GP practices participating in the project with 5 Telehealth Clinics established to connect patients to specialists. Streamlined access to care and coordination for the community using telehealth technology through processes for triage and escalation based on integration of care and provision of services between patients, GP, telemonitoring nurse coordinator, and telemonitoring provider. Patient compliance (performing readings as per GP care plan) was very high. At risk readings comprised 55%, showing that health issues were appropriately detected, escalated and timely managed, preventing unnecessary hospital presentations. 2- Qualitative patient experience “Client who had up to 15 admissions has not presented since clinical intervention and care coordination via telemonitoring”, comment by treating GP. Sustainability: This initiative has transitioned as part of the LHD Chronic Disease Management Program and is now sustained within an ongoing service delivery model. Transferability: This initiative and its model of care has been scaled and rolled-out to other Local Government Areas. The target patients group has also expanded to include chronic heart failure and diabetes. Conclusions: This project provides an integrated healthcare opportunity by co-designing the solution with the GPs and telemonitoring provider, it also enhances patients and carers experience as partners. In addition, the solution is seamless connected care by providing rapid feedback and ready access to clinical support in a sub-optimal serviced locality utilising technology which transforms healthcare. Discussions: This study has served to increase understanding of practical ongoing implementation of telemonitoring in a real world integrated health neighbourhood including a large local health district, a commercial telemonitoring provider and a number of General Practices. Lessons: The missed readings / lost contacts and its interaction with usefulness and reliability of telemonitoring needs to be explored.

Background: Patients requiring haemodialysis have diverse clinical needs impacting on the longevity of their vascular access and their quality of life. A clinical practice scenario is presented that raises the potential of unsafe cannulation of a patient’s vascular access as a result of minimal patient empowerment. Vascular access care is the responsibility of everyone, including the patient and carer. Aim: The aim of this narrative literature review (1997-2014) is to explore the current understanding of what factors influence the care of vascular access for haemodialysis. Method: A narrative literature review allows the synthesis of the known literature pertinent to the research question into a succinct model or unique order to enable new understandings to emerge. The bio-ecological model was used to guide the thematic analysis of the literature. Results: The narrative literature review revealed five themes related to care of vascular access: patient experience; relationships-empowerment and shared decision making; environment of healthcare; time; and quality of life as the outcome of care. Conclusion: The management of vascular access is complicated. Current available literature predominantly concentrates on bio-medical aspects of vascular access care. Contextualised vascular access care in the complex ecology of the patient and carer’s lives has the potential to enhance nursing practice and patient outcomes.

Introduction : The Wollondilly Shire Local Government Area is a peri-urban area located on the south west fringe of the Sydney Metropolitan area facing increasing challenges associated with population growth, health concerns and service provision. Residents have access to local primary care but must travel outside the region for higher level health services. Compared to NSW, there are higher rates of obesity, alcohol consumption, smoking and lung cancer. Short description of practice change implemented : The Dilly Wanderer is Wollondilly Shire Council’s mobile mini bus community engagement and information service. It visits towns and villages in Wollondilly Shire providing information to community members and activities for children and families to participate in. Aim and theory of change : The vision for Wollondilly is that the community is healthier, finds it easier and quicker to access services, enjoys quality services and has a say in the development and provision of health services that affect them. Consistent with the WHO Draft Framework for Country Action across Sectors for Health and Health Equity (2015) the Dilly Wanderer is an exemplar of “action initiated at the local government level…various sectors working together to address public health and health equity issues…through community-based or setting-based health promotion activities.” Targeted population and stakeholders : Potentially isolated individuals and families at risk of poor health due to deficits in social connectedness, health literacy, nutritional choices and physical activity. Timeline : The Dilly Wanderer enhancement commenced in May 2014 and is currently funded to 2017. Highlights : Since May 2015, the following enhanced activities have been delivered via the Dilly Wanderer, all evaluated through satisfaction survey or client experience interview: - Kiosks In addition to the regular Dilly Wanderer timetable, a specific schedule has been established which ensures the Dilly attends a predetermined location each week with the aim of promoting healthy messages and activities. - Special events Due to the increase in the hours of operation, the Dilly Wanderer has been able to attend community gatherings and events not previously attended, boosting overall community awareness and creating a positive brand association. - Workshops/education sessions Information sessions have been delivered to several Wollondilly villages on the topics of child development, parenting skills, healthy eating for families, how to access and identify the need for Allied Health services and basic first aid. The program has been enthusiastically received with all agreeing they would recommend the program to family and friends, 43% confident in making changes to their lifestyle, 63% enhancing their parenting skills and knowledge and 50% feeling a lot more connected to other people in their community. - Walking and exercise groups Walking and exercise sessions have been provided in several Wollondilly villages. The sessions have been well received with over 60 participants to date. Conclusions : Over a short period the Dilly Wanderer has generated positive community engagement, raised awareness, attained solid attendance, expanded its reach and tailored services to health need. Discussions : Community engagement, health literacy and social connectedness can be rapidly improved through mobile mini bus health promotion messaging.

Oran Park Town is located within the Camden Local Government Area of greater south western Sydney. This greenfield development forms part of the first stages of the South Western Growth Centre (SWGC), which over the next 30 years will see over 100,000 additional houses and up to 300,000 additional residents. At present, its population is 3000 people. South Western Sydney Local Health District (SWSLHD) has publicly declared that the future health needs of this growth corridor will be best met through progressive investment in evidence-based primary and ambulatory care, not more hospital beds. The establishment of an Integrated Primary Care Centre network is a key deliverable for this vision. Oran Park Family Health (OPFH) is the first manifestation of this vision, aiming to provide multidisciplinary evidence-based care that is patient-centred and team-based, whilst respecting autonomy and choice. The model implemented in south western Sydney is unique to New South Wales, involving a long-term partnership between the SWSLHD, South Western Sydney Primary Health Network (SWSPHN), Western Sydney University, General Practice and the sole landholder for Oran Park Town, representing a fresh approach to the formation of a private/public partnership in the primary health care sector. It is a model that has been funded through the SWSLHD capital budget to ‘fit-out’ a medical centre in the town centre (shopping complex), purpose built by the developer in direct consultation with SWSLHD and SWSPHN. It is a model that has employed an outcomes-based commissioning framework to procure a General Practice Enterprise, soon to be complimented by commissioned pathology, medical imaging and allied health services, working in a shared space with an existing cluster of District funded primary and community health services. Operating in a federated environment, it is a model that is dependent on the effectiveness of cascading lease arrangements between all parties (landlord, tenant and subtenants), service agreements based on anticipated service utilisation and the good will of independent operators to function under a mandatory Centre Management Committee. The purpose of this presentation is to reflect on our success to date whilst also sharing our lessons learnt as we try to bring our diverse range of partners on our journey to create a truly integrated primary, secondary and tertiary care environment in a localised context where success is the only available incentive. The presentation will also consider our challenges in moving into the next manifestation (Phase 3) of a comprehensive and multidisciplinary health facility operating as a genuine alternative to hospital-centric care.

Introduction : Operating under confirmed Terms of Reference and supported by a signed Statement of Intent, an Integrated Health Committee (IHC) was established between a Local Health District and Primary Health Network to oversee improved integration of services and information between them and other health providers. Under this stewardship, great progress has been made in developing initiatives for a population of 950,000 where locally tailored solutions are delivered balanced with a remit to scale these across this population base. This paper will address the opportunities and barrier of this large-scale and fast-paced health reform and to identify lessons to be learned. Short description of practice change implemented : The Service Model from the IHC has designed around community needs, maximises community participation, harnesses emerging technologies and optimises interagency coordination to address targeted health issues and to facilitate access to a wide range of services and assistance. Aim and theory of change : The aim of the IHC is to strive for a health neighbourhood model in which services are designed to envelope their users, where data is collected and analysed, and technology and shared real-time patient information is available to health care providers to facilitate more integrated and continuous care. Targeted population and stakeholders : The IHC established comprise a range of stakeholders from the Local Health District, Primary Health Network, General Practitioners (GP), senior clinicians, consumers and indirectly with Non-Government Organisations and Local Government. It aims to change the way local residents use traditional health services. The framework conceptualise the governance and support structure to achieve this vision include a strong stakeholders engagement from consumers, health service staff and primary health care workers inclusive of the GP. Timeline : The groups reflect the core integrated care elements and are tasked with identifying and scoping priority models of care and resources required for implementation in order to select suggested areas for action. The partners have acknowledged the importance of articulating a clear vision, provide dedicated resources and the value of working in true partnership with stakeholders. Highlights : The initiatives implemented, under the leadership of the IHC include: - ORAN Park Family Centre - infrastructure - Wollondilly Health Alliance – population and system - Health Pathway – system and infrastructure - Research & Evaluation in integrated care – system These initiatives have been evidenced in filling some of the gaps and issues identified in the region such as improved access to GPs, health service planning in align to population projections and health priorities and connectedness between providers and sharing of clinical information. Conclusions : Integrated care can be implemented successfully in any type of health system and it does not depend on the presence of a single point of control. However, implementation is difficult, and success cannot be achieved quickly. But if the elements and enablers are in place, particularly led by champions, integrated care can work almost anywhere. Discussions : As part of broadening the reach of this endeavour, the IHC has re-engerzing to become an Integrated Care Collaboration operating under a well-defined Governance Framework and Strategy.

Introduction : Telemonitoring may enable early detection of clinical deterioration facilitating early intervention to avoid emergency visits and hospital admissions. Experience of telemonitoring in Australian general practice is limited. The implementation of telemonitoring in South West Sydney is an opportunity to explore how it could be further developed and implemented. In August 2015, 20 telemonitoring devices were introduced to clients in consultation with their general practitioners as a way for delivery of integrated care for distant communities which have restricted access to different levels of health care. This retrospective study analyses the data collected from the telemonitoring project to provide insight into the delivery of telemonitoring, the triage interventions and outcomes from those interventions. Methods : The aim is to analyse the early findings from the telemonitoring data to evaluate and describe the events, as well as to obtain further information to develop an evidence based guide on the model of care and utilization of home telemonitoring. This is a retrospective qualitative and quantitative analysis on the events, interventions and data obtained from the home telemonitoring equipment. Participants were identified as a cohort of COPD patients who had had multiple admissions following discussion with the primary care provider. This study uses de-identified data including a range of information and results on biometrics and chronic condition self-assessment (‘readings’) performed on a routine basis as indicated on the management plan. Data was collected between July 2015 and April 2016. Entry and discharge into and from the programme was staggered. Results : Data was extracted on 18 participants aged 44 to 87. There was equal numbers of males and females. Two participants were discharged due to condition evolving into palliative care needs/facility. 2,932 readings were available for analysis. 55% of readings were of high clinical risk. 25% of readings were within the normal range. 8% of data readings were missed and a further 10% were time delayed as there was no connectivity at the scheduled time. 14 participants had GP escalations. Of the total 93 escalations 23% were related to respiratory conditions. 9 participants had hospitalisations. 51% of hospitalisations were related to respiratory conditions. 1 participant was hospitalised 4 times (only 1 time related to COPD). Overall compliance with the programme was high. Discussion : The analysis demonstrates that selection criteria were generally appropriate but leaves room for further analysis as 4 participants did not need GP intervention at all and 2 participants were discharged to Palliative care. Further analysis would be useful to investigate the actual intervention and outcome when GP intervention was required. Missed data or the loss of connectivity and its interaction with the usefulness and reliability of telemonitoring needs to be explored. The role of technology in integrated models of chronic disease care in primary and hospital care requires further exploration. Conclusion : This project demonstrates a preliminary model for engaging and empowering communities for self-management. It provides a platform for co-designing health service delivery across primary and secondary care. Future research will focus on the model of care, practical barriers and facilitators of telemonitoring in General Practice.

SUMMARY Background Longer, more frequent dialysis at home can improve life expectancy for patients with chronic kidney disease. Increased use of home dialysis therapies also benefits the hospital system, allowing for more efficient allocation of clinic resources. However, the Australian and New Zealand Data Registry statistics highlight the low uptake of home haemodialysis and peritoneal dialysis across Australia. Objective In August 2009, the Australia's HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies. This paper describes the development, achievement and future plan of the Australian HOME Network. Achievements Achievements to date include: a survey of HOME Network members to assess the current state of patient and healthcare professional-targeted education resources; development of two patient case studies and activities addressing how to overcome the financial burden experienced by patients on home dialysis. Future projects aim to improve patient and healthcare professional education, and advocacy for home dialysis therapies. Conclusion The HOME Network is supporting healthcare professionals working in the home dialysis specialty to develop solutions and tools that will help to facilitate greater utilisation of home dialysis therapies.

Up to a 10-fold difference in clinical outcomes between Australian peritoneal dialysis (PD) units exists. There is an international focus on the harmonization of educational practices in PD to determine whether this may lead to improved patient outcomes.The aim of this paper is to evaluate the current teaching practices of nurses and patients in Australian PD units.An online survey with questions on nurse and patient training was made available to PD units in Australia.Thirty-eight (70%) of 54 PD units in Australia completed the survey. A written standardized curricula was utilized in 21 units (55%) for nursing staff and 30 units (79%) for patients, with 23% and 12% including an electronic delivery component for each group, respectively. Universal teaching of adult learning principles was not demonstrated. The hours spent on teaching nursing staff ranged from15 h in 24% to100 h in 21% of units. The average number of hours spent by nurses each day to train patients ranged from2 h in 14% to6 h in 11% of units, with the average total training days ranging from 2 to 3 days in 14% to over 7 days in 14% of units. Staff and patient competency assessments were performed routinely in 37% and 74% of units, respectively.Considerable differences exist amongst Australian PD units in the education of staff and patients. There is a general lack of delivery and competency assessment to meet educational standards. It remains to be seen if harmonization of educational curricula can translate to improved clinical outcomes.

SUMMARY Background: There are currently no published data on the impact of changes to practice caused by introducing coordinated once-monthly erythropoiesis-stimulating agent (ESA) administration. Objective: This study aimed to measure staff satisfaction during and after ESA synchronisation within a single satellite haemodialysis unit. Design: A quantitative survey using a Likert scale was distributed to dialysis nurses pre-synchronisation and during follow-up at three and nine months post-synchronisation. Secondary outcomes included monitoring of haemoglobin (Hb) levels. Results: A total of 19 respondents completed the surveys. By nine months post-synchronisation, most nurses responded that ESA synchronisation was not a time-consuming task, did not increase their workload, had saved them time and was simpler for the unit. Additionally, most nurses reported that they had coped well with the change and that they wanted ESA synchronisation to be permanently introduced. At 8 months post-synchronisation, 53.3% of patients had an Hb level >11 g/dl and

The psychosocial correlates of quality-of-life (QoL) research in end-stage renal disease (ESRD) are important in identifying risk and protective factors that may account for the QoL variability. Thus, the present study provides a meta-analysis of these research results.Published studies reporting associations between any psychosocial factors and QoL were retrieved from Medline, Embase, and PsycINFO. Mean effect sizes were calculated for the associations across psychosocial constructs (affect, stress, cognitive appraisal, social support, personality attributes, and coping process). Multiple hierarchical meta-regressions were applied to moderator analyses.Eighty-one studies covering a combined sample of 13,240 participants were identified resulting in 377 effect sizes of the association between psychosocial factors and QoL. The overall effect size of the association was medium (0.38). Stress, affect, and cognitive appraisal had the largest effect sizes. Location of study, dialysis type, gender, age and QoL domains measured (general well-being, subjective QoL, and health-related QoL) were significant substantive moderators for the associations.The present study shows that there is a moderate association between psychosocial variables and QoL in patients with ESRD, consistent across different QoL domains. The psychosocial constructs that have the strongest association with QoL are stress, affect, and cognitive appraisal.

SUMMARY Objectives: This multicentre, prospective, open label, randomised controlled trial was to determine whether buttonhole cannulation technique in new and established haemodialysis fistula reduced complications and prolonged the access life compared to usual practice. Method: Seventy subjects were recruited for this study. Subjects randomised to the buttonhole group had their fistula cannulated by the same staff member for two to four weeks at the same angle and direction with sharp needles. Once the tunnel was developed, blunt needles were used. The control group continued with usual practice (rope ladder rotation technique). Results: Infection at the cannulation site occurred in four patients in the buttonhole group and one in the rope ladder rotation group (p = 0.11). Haematomas at the cannulation site and site pain experienced during the dialysis session were more often recorded for the buttonhole group (p < 0.05). Conclusions: This study showed that buttonhole cannulation resulted more infections, haematoma formation and site pain during dialysis than with the rope ladder rotation group. A further larger scale longitudinal study is recommended.

Studying psychosocial adaptation in end-stage renal disease (ESRD) is increasingly important, as it may explain the variability in health outcomes unaccounted for by clinical factors. The Brenner et al. proximal-distal model of health-related outcomes provides a theoretical foundation for understanding psychosocial adaptation and integrating health outcomes, clinical, and psychosocial factors (Brenner MH, Curbow B, Legro MW. The proximal-distal continuum of multiple health outcome measures: the case of cataract surgery. Med Care. 1995;33(4 Suppl):AS236-44). This study aims to empirically validate the proximal-distal model in the dialysis population and examine the impact of psychosocial factors on the model.A cross-sectional observational study was conducted with a sample of long-term dialysis patients (n=201). Eleven factors: quality of life (QoL), depression, positive affect, comorbidity, symptoms, physical functioning, disease accommodation, loss, self-efficacy, illness acceptance, and social support were measured by standardized psychometric scales. A three-month average of hemoglobin was used. Latent composite structural equation modeling was used to examine the models.The proximal-distal model with slight modification was supported by fit statistics [χ(2)=16.04, df=13, P=.25, root mean square error of approximation (RMSEA)=0.024], indicating that the impact of clinical factors on QoL is mediated through a range of functional and psychological factors, except for hemoglobin which impacts directly on QoL. The model with additional psychosocial factors was also supported by fit statistics (χ(2)=43.59, df=41, P=.36, RMSEA=0.018). These additional factors mainly impact on symptom status, psychological states, and QoL components of the model.The present study supported the proximal-distal model in the dialysis population and demonstrated the considerable impact of psychosocial factors on the model. The proximal-distal model plus psychosocial factors as a biopsychosocial model can be applied to studying psychosocial adaptation in ESRD.

Department of Nephrology, Royal Children’s Hospital, Melbourne, Victoria, Renal Unit, Royal Adelaide Hospital, Adelaide, South Australia, Renal Office, Concord Repatriation General Hospital, Renal Service, South Western Sydney Local Health District, Sydney, and Renal Department, The Wollongong Hospital, Wollongong, New South Wales, Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; and Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand

Introduction: In March 2014, the NSW Government announced the NSW Integrated Care Strategy to:Transform delivery of careImprove health outcomesReduce associated costs of inappropriate / fragmented care Practice change implemented: A Local Health District LHD and a Primary Health Network PHN have been working collaboratively and developing multiple projects across Sydney’s South West. From this collaboration, an Integrated Care Collaboration ICC group was established in October 2013.The ICC Research and Evaluation R&E Implementation Working Group formed early 2015 oversees and coordinates the research and evaluation strategies related to Integrated Care initiatives. Aim / theory of change: From the implementation of those initiatives and guided by the Population, Intervention, Comparator and Outcomes PICO framework, the ICC R&E group conducted a theory analysis to consolidate each projects’ aims and align the evaluation with the Integrated Care Strategy. The outcome was the development of Common Areas of Research Concepts, each with their Logic Map and Working Group:Timeliness to Diagnosis:Management of ConditionsPrevention of EscalationsSupported Self-management / CareTechnology Enabled Population and stakeholders: Membership consists of stakeholders across multiple tiers of the health system, including government state, federal, local, non-government organisations, private enterprise, and consumer and community participation; collaborating in partnership for the Sydney’s South West community. Timeline: Established 2013 - prospective long-termHighlights: The diversity of initiatives and future evaluation prospects has also encouraged identification of key stakeholders for broader collaboration across organisations.The number of research projects and external partnerships has increased from: 4 x initiatives, 3 x research projects, and 9 x partnerships in 2016; to 9 x initiatives, 18 x research projects and 18 x partnerships.Results from research projects have already proven valuable by providing insight into details of delivering integrated care, understanding of practical issues from implementation of the strategies, advising innovative models for new technologies, and allowing for expansion. Sustainability:The ICC R&E has been able to identify some of the factors crucial for its sustained development, including:Collaborative governance modelEnhanced partnerships and relationship buildingDefined responsibilities and terms of referenceWhole of system approach for resources allocation and project management Transferability: The increasing number on partnerships and initiatives is a result from the replication of the engagement model which has proven successful since the beginning of the original three projects. Conclusions: This collaborative model has provided a stable platform for co-designing enhanced service delivery across primary and secondary care. It has also assisted with streamlining methods and turnkey solutions implementation for identifying and addressing barriers within current models of care, and for research and evaluation methodology and reporting. Discussion: The foundation of Alliances and new ways of collaboration has open the ground for innovation and transference across Local Government Areas, where key stakeholders are identified and become the crucial backbone for the establishment of new partnerships. Lessons: Formulae for maintenance of momentum and drive for development of projects concept to completion has proven to be, in great part, due to the commitment and lead from the Working Groups.

Introduction: In July 2015, HealthPathways HP was implemented by a Local Health District and a Primary Health Network. Type 2 Diabetes T2DM was identified as a priority area. HealthPathways is a dynamic online health information portal aimed at General Practitioners GPs. It supports integration by bringing together general practice and hospital-based clinicians to develop agreed local pathways. It provides guidance for assessment, management, and referral of diverse conditions linked to local resources. New pathways are constantly developed and existing pathways regularly reviewed. Methods: The study used a programmatic approach and mixed-methods including literature reviews, site visits, semi-structured interviews stakeholders and GPs, and surveys GPs and patients to understand the development, implementation and acceptance of T2DM pathways. Electronic surveys were analysed using SPSS Version 20. Cronbach’s alpha was calculated to assess internal consistency of Likert scales responses. Interviews were digitally recorded, transcribed and evaluated using NVivo10 for thematic analysis. Initial codes were abstracted further to identify concepts and categories to generate final themes. Results: 57 GPs responded to the electronic survey. 86% reported awareness of HP and 30% had used diabetes pathways. Of those using diabetes pathways: Over 80% reported it improves quality of care, keeps them informed and supports diagnostic processes 93% agreed information is of high quality and practical 68% reported improvement in referral quality 87% reported assisted in providing more health care in the community and made their job easier Access, workflow and perceived utility were reported as barriers to use Patient survey data including wait times, frequency of clinic and emergency department visits and hospitalisations will form a baseline for later evaluations. **Preliminary analysis of the 12 stakeholder interviews has identified: Implementation Enablers: Key stakeholders’ commitment Seamless networks and collaboration between parties Clear processes and accountabilities Facilitating Factors: Identified as an effective and practical tool with high quality information Supports diagnostic process and patient management Improves referral and triage process for secondary care. Barriers: Longer consultations Prior knowledge and beliefs of health professionals Access difficulties i.e. username/password Increasing size and overly prescriptive nature of website Availability of other online resources Lack of content awareness and how it will add to the consultation/management of patients. Discussion: This preliminary analysis suggest that those who use HP have found it to be a practical tool that supports their diagnostic and referral processes and provides information of high quality. However, there may be a lack of awareness of the HP within general practices. Conclusions: HP is reported to be an effective tool which has improved referral and triage process for secondary care. It helps in improving patient outcomes and management. Lessons: Early evaluation of the pathways can only provide information on development and project implementation, rather than clinical outcomes. Study Limitations: Small survey sample size; Low GP recruitment Suggestions for Future: Broader scope for evaluation of multiple pathways to identify the best ways of ensuring sustainability, identify outcomes related to patient care and provide lessons for other regions. **NOTE: Currently on final stages of qualitative data analysis.

Studies have shown that patients converted to short daily haemodialysis (SDHD) have reported many clinical benefits, decreased complications during dialysis and a better quality of life.A six-month prospective cohort study was conducted to examine the efficacy of SDHD to patients previously receiving three times per week haemodialysis therapy. Following informed consent, participants received haemodialysis daily, Monday-Saturday, between 2 and 2.5 hours for each treatment and followed-up for a six-month period. The participants continued to experience hypotension, cramping and headache and were noncompliant with fluid intake. There was a gradual reduction in blood pressure, cessation of antihypertensives and reduction of erythropoietin therapy (ERT). There were no hospital admissions or reports of access complications. The nursing staff reported an increase in activity levels and nursing interventions with the participants following conversion to SDHD. However, the participants reported a better quality of life.

Background and objectives: Kidney disease–related loss is clinically significant in patients with ESRD and is related to depression and quality of life. The Kidney Disease Loss Scale (KDLS) was recently developed for long-term dialysis patients as a means of studying loss and applying it to clinical practice; however, its validity and usability in the other developmental stages of ESRD—predialysis and early dialysis—remain unknown. This study examined the validity and reliability of the KDLS in the long-term dialysis, early dialysis, and predialysis populations. Design, setting, participants, & measurements: Four groups of participants were recruited from four large university teaching hospitals in the Sydney metropolitan area. Participants were long-term dialysis (n = 151), early dialysis (n = 163), and predialysis (n = 111) patients. An additional independent group of dialysis (n = 50) patients were recruited to measure the test–retest reliability. Multisample confirmatory factor analysis and correlational analysis were used. Results: Results demonstrated good internal consistency and test–retest reliability for KDLS. Multisample confirmatory factor analysis indicated that the factor structure of KDLS was invariant across samples and thus supported its construct validity. The convergent and discriminant validities of KDLS were supported by its correlations with scales that measure health-related quality of life, depression, and positive affect in the expected directions and magnitudes. The KDLS was sensitive to the developmental stages of ESRD. Conclusions: These findings demonstrated that the concept of loss exists in dialysis patients. The KDLS is a reliable measure of loss in ESRD and valid in the developmental stages of ESRD.

Introduction : HealthPathways is an integrated care approach that brings together general practice and hospital-based clinicians to develop agreed local management streams and pathways, and document these on an easily accessible website. It provides general practice teams with clinically relevant guidance on the assessment, management, and referral of a range of conditions, which are linked to locally relevant resources. In July 2015, HealthPathways was implemented by a Local Health District (LHD) and a Primary Health Network (PHN). Type 2 Diabetes (T2DM) was identified as a priority area. Methods : This is a programmatic evaluation on the development, implementation and acceptance of T2DM pathways, with qualitative and quantitative data being collected and analysed from a range of sources to better understand the pathways implications and applications. This study uses data from: HealthPathways working groups Online survey responses from General Practitioners (GPs) Semi-structured interviews of: Stakeholders (e.g., LHD and PHN staff) GPs who use the T2DM pathways Anonymous surveys of patients at diabetes clinics HealthPathways web server utilisation data Interviews are digitally recorded and transcripts analysed using a thematic analysis approach – with initial codes generated directly from the participant’s words. These codes will be abstracted further to identify concepts and categories to generate final themes. Results : NOTE: This project is currently recruiting participants and undergoing analysis. Current results indicate that 68% of GP respondents use HealthPathways, with 39% on a daily to weekly basis and nearly half (47%) use HealthPathways in caring for a patient with DM. Thematic analysis from stakeholder interviews emphasise the importance of established collaborations and the need for standardized tools with common priorities and transparency in processes. Discussion : This preliminary analysis suggest that those who use HealthPathways have found it to be a practical tool that supports their diagnostics process and provides information of high quality. However, it also highlights that there is a lack of awareness of the HealthPathways within general practices. Conclusions : HealthPathways has been live for 18 months and is still under development Due to early evaluation of the pathways, clinical outcomes data is not in the scope Lessons : Early evaluation of the pathways can only provide information on development and project implementation, rather than clinical outcomes Implementation Enablers : Key stakeholders’ commitment Seamless networks and collaboration with steering committee and working party rapport Clear processes and accountabilities for project management and implementation Study Limitations : Analysis of only one specific pathway has proven to be a barrier for GP recruitment Project design dependent on volunteer participation for two arms of the study Extent of dynamic engagement Access to Diabetes Clinics Suggestions for Future : Broader scope for evaluation of multiple pathways Further enquiry into the experiences and practical implementation of the HealthPathways within the general practice business model (including referral to specialised services) Evaluation of clinical outcomes and patient experience Cost analysis for impacts on lower duplication of pathology/imaging studies and hospitalisations Potential impact on streamlining patient flow through the health system and decrease on avoidable hospitalisations due to early identification and timely management of targeted conditions