Maintaining Continuity of Care in a Transient Environment

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1 Maintaining Continuity of Care in a Transient Environment Anyinginyi Health Aboriginal Corporation Culturally Responsive Leo Curran Renal Nurse Coordinator

2 Flynn Drive Renal Unit Alice Springs Renal Dialysis Unit Tennant Creek Anyinginyi Health Aboriginal Corporation Tennant Creek

3 40% Comparison of Clients 35% 30% 25% 20% 15% 10% 5% 0% Alice Springs Barkly Central Australia North Central Australia South Percentage of Patients on Dialysis Patients with CKD

4 Commenced on RRT 35% 65% 19 months Pre Management Change 19 months post Management Change Commenced with an Access Commenced on PD 33% 21% 19 months Pre Management Change 19 months post Management Change 19 months post Management Change

5 EGFR Below 20 3% 3% 3% 7% 17% 50% 10% 7% On HD ON PD Fistula in Place Fistula Planned Conservative Management Transplant Refused Others

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10 The renal team only visit Anyingingyi 3 monthly for CKD clinics. During these clinics, a maximum of 20 patients can be seen. This means that not all patients can be seen at Anyingingyi during these clinics. The renal case manager is able to monitor and review patients closely and determine who needs to be seen in the clinic or who can be discussed without being seen, or perhaps be reviewed via Telehealth. There up to 8 Renal Physicians who rotate through the clinics. This means the patient may not see the same physician. The Renal Case Manager offers consistency and is able to build a trusting relationship with the patient. If the patient does not attend the clinic appointment, then they may not be seen by the renal team for another 3, 6, 9, 12 months or more. Even without being seen, the Renal Case Manager can provide monitoring, reviews and education to the patient and maintain the contact with the team so that the best possible care is provided.

11 The Renal Case Manager has established relationships and ongoing communication with all aspects of the renal team. These team members include: Renal Physicians, Chronic Kidney Disease Coordinator, Renal Access Coordinator, Peritoneal Dialysis Coordinator, Transplant Coordinator and Social Worker. These relationships allow for ongoing planned care and best possible outcomes for patients. Without the Renal Case Manager, patients would receive intermittent education or may never receive this education. Without ongoing, regular and consistent education, it is more likely that patients will progress to End Stage Renal Disease at a more rapid rate. Patients who receive the education are more likely to understand treatment options, have planned renal access in a timely manner, make plans for the care of family members or if they choose not to have renal replacement therapy then they can be supported in this decision. Hayley Connelly, CKD Coordinator, Flynn Drive Dialysis Unit, Alice Springs

12 The Anyinginyi Health Renal Case Manager, Leo Curran RN, has been of great support to me in Tennant Creek. I have two Peritoneal Dialysis patients at TCK and Leo sees them at his clinic every fortnight or so to monitor their progress and when necessary does home visits. Because of the high risk of peritonitis with PD clients, and the complex issues involved, it would be very difficult to organise these clients on an outreach basis. In fact it is only since the appointment of a Renal Case Manager in TCK that we have been able to seriously consider commencing these two clients on PD. All the very best from, Job Chundanga, Clinical Nurse Consultant, Peritoneal Dialysis Unit, Alice Springs Hospital.

13 The renal case manager at Anyinginyi Health Aboriginal Corporation has undertaken all follow up for renal transplant clients. Up until last year, the RDU had had responsibility for these clients, which put an extra burden on our staff and facility. Any RDU clients requiring dressings for infected wounds are referred to Anyinginyi. At times when there has been no diabetic educator available, the renal case manager has acted in this capacity to provide instruction and supervision for RDU clients who required daily insulin. Previously clients who were not competent at self-administration would only receive their insulin on dialysis days. In the near future, we plan closer liaison with regard to medication prescriptions and ASH OPD appointments for RDU clients.

14 The Bloodhound Gang!

15 Flynn Drive Renal Unit Alice Springs Renal Dialysis Unit Tennant Creek Anyinginyi Health Aboriginal Corporation Tennant Creek

16 Thankyou