Pain medicine: taking it to the streets

NOVEL APPROACHES TO WAITING LISTS

View Slides

C Hayes
Hunter Integrated Pain Service, Newcastle, NSW

Introduction

Hunter Integrated Pain Service (HIPS) is a multidisciplinary team based in the public hospital system in Newcastle, NSW. The team is part of Hunter New England Area Health Service, which covers a region approximately the size of Victoria and a population base of 840,000. In common with the majority of public hospital based pain services, HIPS faces an enormous challenge with waiting list management.

Excessive waiting times reflect a dysfunctional system and impact negatively on morale. Strategies are needed to balance rate of referral with capacity to treat patients. If pain centre resources are inadequate there is a need to support appropriate strategy beyond our service borders. In other words, we need a health promotion role in addition to our traditional model of face-to-face service delivery.

The Problem for HIPS

In 2004 HIPS was operating at full capacity with annual occasions of service consisting of 400 new outpatients, 200 new inpatients, 1400 outpatient reviews and 600 procedural interventions. Referral rate was around 80 patients per month (960 patients per year). The waiting list exceeded 500 patients. Non-prioritised patients were waiting 2-3 years for assessment.

Developing a Community Based Multidimensional Approach

A novel approach to waiting list management was initiated in October 2004. Multiple levels of need were addressed. Fundamentally, there was the need for community attitudinal shift. There was the need to support primary health workers to manage pain effectively. The need for coordinated strategy within specialist and hospital-based systems was also recognised. HIPS approach has been developed in collaboration with the Hunter Urban Division of General Practice. The system continues to evolve.

Development of the HIPS website (www.hunter.health.nsw.gov.au/hips) has been crucial. Key aspects of the strategy have included:

1. Community Attitude: We have been promoting concepts of “the message of pain” and the “journey of pain”.
2. Referral criteria, waiting time targets, and discharge criteria were defined.
3. A general practice telephone contact clinic commenced.
4. A Pain Self-Assessment Questionnaire (PSAQ) has been developed to encourage lifestyle review.
5. The web based Community Information Series targets public education.
6. The web based Medical Practice Guidelines support GP’s and others to manage persistent pain without necessarily needing specialist referral.

Outcomes

Implementation of the initial phase in October 2004 enabled the cancellation of a waiting list of approximately 500 patients. Re-referral was offered according to new criteria.

1. The GP telephone contact combined with a policy of earlier discharge has increased HIPS capacity to see new patients from 600 to 900 per year (ie. from 50 to 75 per month).
2. Average referral rate over the past 6 months is approximately 75 per month. This means that referral rate and capacity are in balance.
3. Current triaging patterns direct 10% of referrals to urgent medical assessment, 30% to high priority assessment, 35% to moderate priority assessment and 25% to GP telephone contact.
4. After GP telephone contact 50-60% of cases are discharged without the need for face-to-face contact.
5. Waiting time targets are currently met with the exception of some delays in GP telephone contact.

Future Directions

Collaborative discussion is needed with pain centres, GP’s and other interested parties to develop community interface strategy across Australia. Varied approaches to challenging public attitudes to pain can be considered. Improved systems of outcome measurement are needed. Simple measures could include referrer and patient satisfaction. More complex measures could address patient progress over time. We need improved screening assessments that can guide more specific and resource efficient management approaches.

Time of Presentation
Saturday 13 May 2006 - 1330-1500