TASK

Your task is to develop a proposal for an innovative model of care (or process improvement) and/or advanced Orthoptic practice. Your group should select to focus on an issue you noted whilst on clinical placement. You may use an efficient model of care, process or practice you witnessed in one practice and suggest it for another where this did not exist and could improve the service.

 

1. BACKGROUND

Healthcare systems are continuously seeking to deliver the best potential outcome for the patient and the healthcare provider. Whether it is a public or private hospital or smaller clinics, the ability to recognize arising issues with the delivery of healthcare is of utmost importance. By identifying the issue, it allows the individuals responsible to evaluate the extent of impact on the current model and develop techniques to resolve it, resulting in a more efficiently operated service. As the healthcare sector is constantly advancing, issues will inevitably arise. Hence the need for innovative model of care proposals to counteract these issues and provide improved healthcare delivery.

In regards to the field of Orthoptics, particular problems were observed while on placement that could be improved upon. A specific issue that attracted our attention is the substantial amount of patients who fail to attend their appointments. Failure to attend (FTA’s) is when a patient does not present to a scheduled appointment or cancels the appointment. Failure to attend is an increasingly undesirable problem with rates being 5%-39% worldwide (Collins, Santamaria, & Clayton, 2003). As there is increasing pressure on healthcare systems to see more patients and at faster rates, this issue is impeding the efficiency of healthcare delivery. Research suggests that the most common reasons patients provide for not attending include: transport availability and cost (Masango-Makgobela, Govender, & Ndimande, 2013), forgetting the appointment, increased age and appointments for particular diseases (Shaparin, White, Andreae, Hall, & Kaufman, 2014).

At face value, FTA’s appear insignificant to the healthcare model and only directly impacts the patient. However this is a misconception as it has various consequences regarding the patient and also the healthcare provider. Continuously missed or cancelled appointments cause major inadequacies for healthcare delivery. To begin with, there is an economic cost associated with each missed appointment (Murdock, Rodgers, Lindsay, & Tham, 2002). Especially in public hospitals, each appointment for an outpatient is costing the system money and as FTA’s numbers increase, the total cost of missed appointments rises dramatically.  Another problem caused by the increased number of FTA’s is the underutilisation of clinical staff and equipment (Downer, Meara, & Da Costa, 2005). When a patient fails to attend their appointment, this adds to the waiting period of other patients and their ability to be consulted by a healthcare provider. This below average utilisation of equipment and manpower represents delays and prevents an efficiently managed system. Finally, deterioration of patient health is another concern when evaluating the issue of FTA’s. When a patient does not attend their appointments, there will be delays in diagnosis or treatment. This will inevitably result in regression of the symptoms or illness (Murdock, Rodgers, Lindsay, & Tham, 2002).

For the above reasons, a proposal is necessary to improve this model of care and provide a higher standard of healthcare delivery. The aim of the proposal is to decrease the number of FTA’s, in ways that will be both easy and cost-effective for the healthcare provider and patient. These means will be further discussed in the appropriate section.

 

2. CURRENT MODEL OF CARE / PRACTICE

Throughout clinical placements and thus exposure to public and private hospitals and clinics, a greater understanding of the rates of FTAs is acquired. There have been instances in which only one of five patients booked into an orthoptic led clinic in a public hospital attended their appointment for unknown reasons. In another instance, a patient in a public hospital with a previous FTA complains that they did not attend their previous appointment due to receiving their letter reminder after their appointment date. These examples highlight that there is a clear problem in the current system implemented for FTAs, particularly in public hospitals. There are many other problems with the current policies enforced, some of which include lack of education around the hospital or clinic’s policies and the lack of consequences for FTA’s.

Every hospital and clinic have their own protocol that they follow for FTAs, however most public health care systems in Victoria follow the access policy for ‘specialist clinics in Victorian public hospitals (Department of Health & Human Services, 2013,). This document provides suggestions supplied by the department of health that cover aspects of the health care system from referrals to waiting lists and FTAs (Department of Health & Human Services, 2013). It is important to understand that the document provides merely suggestions and thus they may not all be implemented in health services. The document outlines the following proposals on dealing and preventing FTAs for public health services:

• If the patient fails to attend their first appointment on one or two consecutive visits without an appropriate reason or not informing the public health service within 24 hours of the appointment, then they may be taken off the waiting list (Department of Health & Human Services, 2013).
• When a patient FTAs, they should be rescheduled for another appointment and if they do not attend on two consecutive occasions then they may be discharged in which the patient and their GP is informed of the discharge (Department of Health & Human Services, 2013).
• Appointment reminders should be sent to patients to avoid FTAs
• Appointments should be patient-focused in which the patient chooses a time that is suitable for them to increase the chance of the patient attending (Department of Health & Human Services, 2013).
• Public healthcare systems should inform the patients of the consequences and the hospital’s protocol of not attending their appointments (Department of Health & Human Services, 2013).

 

Some of the proposals implemented in public hospitals may be applied in private clinics and hospitals as well, however there are a number of variations in their protocols. Private clinics, in most cases, call or send their patients a confirmation letter or SMS as a reminder of their appointment. Private clinics often employ a strike system in which on the patient’s first FTA, it is noted on their file. On their second FTA, the note on their file is often highlighted and the patient is contacted to confirm a future appointment and informed is of the consequences of a third FTA. On their third FTA, some clinics may have a specialist review the patient’s case for future appointments with the clinic (Wickham Park Surgery, 2019). The clinic may also take extra precaution by sending their usual reminder letter or SMS but also call the patient before their appointment or pay a cancellation fee (Modern Medical Caroline Springs, 2019).

The main drivers for change to reduce FTA’s include providing appointments for patients that genuinely need them, providing better health outcomes and reducing the amount of pressure, costs and time wasted by clinicians waiting for patients to arrive to their appointments (The Bellingham Practice, 2019; Williamson, Ellis, Wilson, McQueenie, & McConnachie, 2017)

3. PROPOSED MODEL OF CARE / PRACTICE
   
   As mentioned above, non-attendance in outpatient appointments has proved to be a major issue in the health care sector. Many individuals who miss appointments do not receive the proper care they may require and thus can have a multitude of negative impacts on their health and well being. Specifically, in the ophthalmology sector, many eye related morbidity can be avoided with timely eye care services. Individuals who fail to attend, may directly sense the impacts of not receiving the care they require in a timely manner. They may miss vital information and may delay treatment regimes. Conversely, other individuals may also be indirectly impacted by the individuals who did attend their appointments. As resources are scarce as is, many individuals may miss out on time slots occupied by the ones who fail to attend. Doctors and staff also waste a lot of time following up on patients who do not attend as opposed to utilizing that time in providing care for the individuals who are present and may require vital care. Such instances of health care professionals misdirecting their time used for patients vs chasing up patients who did not attend, impacts the overall efficacy of a clinic and can cause a burden and additive cost on the health care system. Furthermore, illustrating that addressing and above all implementing systems to reduce the number of FTA’s is essential in ensuring all patients receive the best quality of care. The benefits to reducing the number of FTA’s will also mean that budgets can be utilized in areas more beneficial to the overall health care system.

Currently many models are being utilized however FTA’s still prove to be a grave issue within both private and public health care sectors. As previously stated, within the public system, patients who cancel appointments consecutively without valid reasons are removed off waiting lists. In order to improve the rates of attendance patients are able to choose appointments that suit their lifestyle and are provided with various means of reminders. As a result of technological advancements such as text messages and email, proving multiple notifications to patients has been linked to improve overall effectiveness in health care settings. Nevertheless, FTA’s are still widely prevalent. Critically appraising the current systems and enhancing the deficits is essential. It is evident that at present, systems lack adequate acknowledgement of broader issues and contexts. Solutions to this challenge is achieved through employing techniques that involve a robust evaluative framework. It is key to remove any obstacles and barriers in providing such care and this can be achieved by assessing all causative factors. Alternatively, utilizing a more holistic approach considering all physical, social and financial circumstances, a more advanced proposal in improving appointment attendances can be put into place.

In order to improve on current systems key determinants in obstructing patients must be considered. Often times patients lack education about their illness and the progression of their disease should they miss their medical appointments. Health care professionals play a vital role in enlightening patients of their illness. In addition to this, they also need to inform patients of the implications they may face if they do not attend their appointments. In doing so, the professionals themselves should consider learning methods of delivering patient education in a socially and culturally appropriate manner. Education should not be limited to only clinical practitioners but all members of staff such as translators and receptionists so that the appointment making process is at most optimum level. The clinicians should learn to limit medical jargon where individuals are not well-informed or uneducated and limit coming across as condescending in dialogue to those who do not come from an English speaking background. Additionally, great service provides an incentive for patients to return, whereas poor service only leads poor return numbers. When clinicians are warm and deal with patients in a calming manner, it encourages positive relationships and allows them to feel safe and results in a long-term bond.

Proposed solution:

Choreographing education seminars for health care professionals and all members of staff on methods to convey information that encourages attendance. These seminars will be designed to cater to excellent customer services. These seminars will also demonstrate to orthoptists how to appropriately teach patients about their condition, including its: treatment, prognosis and what occurs during an appointment.

1.   Under the program, patients will be directed to an online hub where they are able to learn about their condition. This provides a constant resource, from which patients can learn and review. This would help the patient better manage their condition and make appointments easier.
2.     Conducting courtesy calls and performing audits for reasons for failures in attendance and revisiting potential solutions in conferences to break more barriers.

 

Another proportion of patients who contribute to high rates of FTA’s within the healthcare sector lack is as a result of lacking adequate notification of their appointment times. They may understand the severity of their illness and the importance of attending appointments in relation to their disease progression they mistakably miss their crucial appointments. Postal letters can be missed due to changes of address and can be forgotten if the dates are not within a few days of the appointment. The advancements of technology mean emails and SMS texts can be automatically delivered to patients within close proximity of the appointment dates multiple messages can also be sent and therefore increasing the likelihood of the patient attending.
Proposed solution:

1. Sending multiple automated SMS texts to patients in timely intervals leading up to patient appointment. One text to be received one month then one week and one day prior to their appointment.
2. Providing patients with a choice of preferred method in receiving notifications most convenient to them.
3. As part of the online hub, patients would have access to an online appointment maker. Where they would be able to change their appointment according to their own schedule. Other patients of the same condition would be part of the schedule, so that if a patient moves their appointment, another can take their place.

FTA rates can also be impacted by the financial situations of patients. Transportation and the like can become physical barriers to attending their appointments. As health care professionals, proposing schemes in assisting the patients in attending their vital appointment becomes crucial. The health system is focused on patient centered care. Professions should aim to devise systems to provide financial aid for matters such as transport for those who need it. Linking eligible patients with various charters can limit transport related FTA’s. All in all, ensuring that patients attend their appointments and receive the best quality of care.
Proposed solution:

1. Orthoptists’ play a significant role in the allied healthcare profession. This could involve presenting protocols to governments to provide additional funding to clinics. Specifically, providing patients with transportation help if they are in a position where they are unable to physically attend their appointment.
2. Funding could include, providing taxis or Uber to patients who are unable to physically make their way to the clinic or at least reimburse some of the travel costs.

 

4. PROVISIONAL BUDGET
   

By proposing a change to the existing healthcare system model, a cost will most always be associated. For this reason, the budget for any proposal must be assessed. For this specific proposal, the cost of labour (Orthoptists/ medical assistants/computer clerks) and SMS/letter reminders must be considered.

This proposal is aiming to reduce FTA’s through reminding the patient of their appointment date and time. As discussed, this could be managed in several ways including text messaging, phone calls or letters sent home to the patient. When weighing up these options, it was found that SMS’s sent to the patients mobile phone was the most efficient and cost effective method when compared to reminders via other means (Gurol‐Urganci et al., 2013). By using SMS reminders, an automatically generated message could be sent to the patient via a reminder messaging service. An example of this is the Telstra Mobile online SMS business system which allows automated text messages of up to 160 characters to be sent to the designated person (Downer et al., 2005). The service will need a computer clerk to begin by inputting patient data or details into the system. The salary of the computer clerk would be about $18 an hour (Downer, Meara, Da Costa, & Sethuraman, 2006). A study for a 63 day period indicated that a for the amount of time the clerk would need to organise messages, the salary would be about $180.00. There is also an additional cost of about $0.22-0.25 per text message sent by the SMS system (Downer et al., 2006). This varies according to the amount of SMS’s forwarded.

As mentioned above education will be needed to improve patient attendance. This could also be achieved through a few different ways including a letter/pamphlet sent to the patient’s address, through SMS messaging or on the day of their actual appointment which they attend. As mentioned previously, SMS messaging comes at a lower cost compared to other methods and so could be more cost effective. Therefore, the SMS system can be used to send a message to the patient educating the patient of the seriousness of their disease and their need to attend scheduled appointments. This would also cost about $0.25 per message and again with the added extra cost of the clerk responsible for sending the messages. Another way a patient could be educated, is through the appointment they attend. This comes at no extra cost to the system, as it is done through the cost of the appointment itself however there will be the cost of the appointment. At a public hospital the appointment itself would cost the healthcare system about $151.00 (MyDr.com.au, 2019).

Costs associated with cancellation fees issued after several FTA’s, include mostly the mailing of the fee to the patient. Policy regarding cancellation fees can be posted onto the hospital website so patients could be informed of this change. This comes at no extra cost to the healthcare facility as it is readily available to all and requires no further attention. However, when there is a need for a cancellation fee to be issued there will be an added cost. The cancellation fee will need to be posted to the patient’s address; thus a postage fee will need to be accounted for. The cost of letters sent to patients is about $1.00 per letter (Australian postal corporation, 2019).

These costs are all subjective and may vary depending on the hospital/clinic, experience of orthoptists/ computer clerks, location of the facility and the amount of patients that FTA.

 

5. BENEFITS OF PROPOSED MODEL OF CARE / PRACTICE

The advantages of the reduction of FTA rates are great and have a widespread positive effect on numerous features of the ophthalmic sector. The suggestions proposed to reduce FTAs can lead to the following benefits:

Education: There are many studies that show that there is a correlation between FTA’s and the patient’s lack of education in relation to their disease, treatment or healthcare service. Understanding solely the prognosis of a disease and the effects a pathology may have on a patient’s way of life allows the patient to become aware of the significance of maintaining compliance with appointments and treatment. Education diminishes the fear of the unknown and the anxiety associated with appointments and navigating the healthcare system, which has been reported to be a cause of FTAs (Powell & Appleton, 2012). Thus, the benefits that education carries not only include the reduction of FTA rates, but compliance to treatment regimen, increasing confidence in a patient which will allow them to have a more optimistic approach and a greater engagement with the healthcare system

Audits/Monitoring:  The use of audits are widespread in the healthcare system because they allow the practise or hospital to identify problems in their systems and allow them to act upon them. Performing audits of FTAs will highlight the potential reasons and patterns associated with attendance rates and as a result, providing the solutions of the features of the health service that need to improve to allow for progress (Toy, 1994).

Improved reminders: Improvement of appointment reminders through the use of SMS texts sent in timely intervals before a patient’s appointment will greatly increase attendance rates. There are many issues that arise with the sending appointment times and reminders via letters, including the change of addresses and failure to receive these letters due to postal issues. Thus, opting for SMS messages, specifically timely reminders of appointment times, will maximise the likelihood of attendance as one of the most common reasons for FTAs is forgetfulness (Head of Practice Governance, 2018; Powell & Appleton, 2012).

Improved time and financial management: It is concerning the costs and the time wasted with FTAs, particularly when they can be utilised in more effective ways (Powell & Appleton, 2012). The benefits of targeting FTAs can potentially relieve some of the burden placed on the public hospital waiting lists and time and costs can be allocated and directed at other pressing issues in the healthcare system.

Cancellation fees: The use of cancellation fees, particularly in public hospitals, will provide patients with a major incentive to attend their appointments. One report studies patients who continuously fail to attend their appointments and highlights that one of the reasons as to why they fail to attend is because they believe they can always book another appointment (Williamson, Ellis, Wilson, McQueenie, & McConnachie, 2017). This displays the lack of value for public healthcare systems and thus implementing a cancellation fee will target this issue directly.

 

 

6. EVALUATION
   
   Audits if FTAs actually decreased and why. Evaluation form and questionnaire in patients if they’re more inclined to attend appointments. Surveys. *
7. Indicate the evaluation criteria you will use to assess the program and how it will be performed (e.g. how long will you wait until you evaluate the program).
8. Prepare Evaluation Form(s) for data collection
9. Indicate how you will ensure ‘continued’ quality and improvement of program

 

7. IMPLEMENTATION

Our strategy is to implement a program which aims to prevent failures to attend (FTA), through education and an active patient role in the management of their condition. Comprising many features and strategies, the program will see the orthoptist taking on a ‘teaching role’, whilst also giving patients the self-efficacy to help in making their own decisions. The program relies on a strong knowledge base and ability to teach from the orthoptist, meaning that additional training may be required. The wide-ranging program will aim to include: orthoptists continually teaching patients with regards to their condition, giving patients online resources and innovative methods to help patients comply with attendance. Though the overall aim is to reduce FTAs, the program also helps the patient through education and better self-management.

A major barrier to patient compliance is their knowledge about their condition. Patients often do not know about their: disease, treatment and prognosis. Patients with diabetic retinopathy often do not seek treatment or attend appointments because they felt that their eyes were fine (Vengadesan et al, 2017). For example, though management can reduce severe vision loss risk by 90%, under half of the 29.1 million diabetics in the US attend eye screenings yearly as recommended (Liu et al., 2018). Therefore, educating the patient thoroughly about their condition and especially the risks of non-compliance is crucial. For example they must be able to dispel myths about their condition, such as dependence on insulin (Duan et al., 2017). Under the proposed program, orthoptists will require ongoing education as well as training in teaching. This training will allow orthoptists to better manage patients, through being able to accurately explain: management, treatment, prognosis, etc. to patients. Although orthoptists may be able to explain about conditions, they must also be able to do this appropriately. During placement, students as well as orthoptists often found that though they knew how to explain concepts to most patients, others found them difficult to understand. That they were not clear and had to confirm their ideas with the ophthalmologist. Therefore, we propose that orthoptists would be trained in annual seminars on how to educate patients in a socially and culturally appropriate manner. All grades of orthoptists should be able to participate in this program, and students would also find it beneficial to attend the seminars. This would allow them to better learn whilst on placement and better understand how to see patients. The seminars could be individual sessions or a part of existing seminars run by orthoptics organisations. The presenter could be an orthoptics professor or a teaching professor, who is knowledgeable in individual teaching of adults. Each individual seminar would review educational concepts required and adapt new concepts to improve teaching patients.

Although the orthoptists will be able to convey information properly to the patients, the patients themselves should be encouraged to take more of an active role to manage their condition. Better outcomes are achieved when patients are involved in their treatment, as when decisions are made for the patient, this reduces their responsibility and compliance (Marahrens et al., 2017). In this study, 74.3% of 806 participants preferred shared decision making (SDM) compared to 17.4% who preferred ophthalmologist-dominant decision making. Therefore patients of chronic conditions would be enrolled into an online hub with information about their condition. There, they would also be able to ask related questions with orthoptists able to post answers. Patients would thus be able to learn more about their condition, have a convenient resource which they could always have access and be able to ask questions of a qualified expert. This would give patients the ability to learn about their condition and also the: management, prognosis and what is done in clinic. The patient would then be better equipped to participate in clinic and thereby gain better outcomes. This encourages the patient to learn about the condition on their own, rather than forcing them which does not lead to an increase in follow-up appointments. This was conveyed in the use of ‘patient contracts’, where patients signed on to a contract requiring them to comply with ‘healthy behaviours’. Despite the contract, 38.1% of the contract group and 43.9% of the non-contract group attended an appointment in a determined time frame, despite abnormal results found. Thereby, contracts and placing requirements on a patient did not improve attendance rates (Aleo et al., 2015). These features of the program address patient’s knowledge of their condition as a barrier of attendance and treatment. This affects many patients, for example, in a study by Thompson et al. (2015) though most of the population were college-educated, spoke English and were aware that follow-up appointments were important, those who answered less than 50% correctly of questions about their eye condition were significantly more likely to FTA. Further the study found that most of the participants received their knowledge about their condition (including glaucoma, macular degeneration and diabetic retinopathy) from the ophthalmologist and that they did not receive enough resources. This feature would likely not require orthoptists to be trained as it relies on the patient accessing an online hub independently. The orthoptist would be required to be able to answer questions about the condition, and they should be able to do so with their university knowledge and experiences with online forums. In order to maintain care and accuracy, we believe that the orthoptists who monitor the online hub must be registered with Orthoptics Australia and at least grade 1, i.e. in the workforce. Students may feel unsure about answering patient questions, and it would take considerable time for professors or orthoptists to verify their answers.

Another feature of the program involves improving administrative processes. Whilst lack of health literacy is an important barrier of attendance and treatment, other barriers such as travel considerations can also significantly decrease ability of the patient to adhere to instructions. For example, 33.7% of patients in a study between 2010 and 2015 stated that they had not had any eye examinations in that period (Moinul et al., 2018). In another study, 49% of FTAs described no escort or inability to find travel as a reason they FTA (Vengadesan et al., 2017). For this reason, we propose that patients would be put on a text message/call/letter list but also an online appointment creator that is adjustable could be created for patient use. Patients would also be given the option of an uber or taxi service. Patients put on the list would receive numerous reminders close to the date of appointment, allowing them to confirm attendance. The online appointment creator, would provide patients with the ability to change the appointment according to their own schedule. Patients could also be given the option of an uber service, to help them attend the clinic. Orthoptists would not require additional training for these services, however they would have to explain to patients how to use these services. Any grade of orthoptist would be able to provide these services, they likely would be able to explain how to use the systems to patients or even operate the systems on behalf of the patient. Under the proposal, orthoptists would ask for funds from the government, however if not possible the cost would be added to the cost of patients consultation.   The program would take time to become thoroughly effective, patients could possibly find the online hub difficult to manage. However, we believe that through constant feedback and modification, eventually the program would run efficiently and reduce FTAs.