VISITING YOUR LOCAL GP PRACTICE: A GUIDE

VISITING YOUR LOCAL GP PRACTICE: A GUIDE

WHY? WORKING WITH YOUR LOCAL GP In 2012-2013, only 1.1% of GP counselling/advice involved exercise (1). Each patient encounter is an opportunity for clinicians to make a difference (2). Brief interventions in primary care settings are an effective way of increasing physical activity among adults (2,3), and the Global Advocacy for Physical Activity supports the use of brief interventions linked to community based support for behaviour change (3,4). In Australia, we re working backwards. We have the existing resources and infrastructure including the specialised workforce of accredited exercise physiologists and the public and private rebates which enable Australians to access these services. Primary care has been identified as an ideal setting to begin lifestyle modification and we need to significantly increase the number of clinicians counselling their patients on physical activity and referring or prescribing exercise. A GUIDE TO ESTABLISHING SUCCESSFUL AWARENESS OF AEPS Exercise is the best, cheapest, most accessible medicine available. The problem is, assessment and measurement is complex and exercise doesn t come in an easy to measure package (5). Self reported levels of exercise are often over estimated, and objective measures such as pedometers, accelerometers, heart rate monitoring are becoming more common outside the fitness industry, moving into healthcare. You can support GP clinics in your area to embrace physical activity and exercise referrals. This guide will assist you to get your foot in the door with practices in your area, and get your message across clearly and concisely. ESTABLISHING CONTACT When making first contact with a practice the goal is to make an appointment to see an individual GP or nurse, or a group of clinicians in that practice so that you can introduce yourself and your services in person. GPs are more likely to refer to a person or program if they have met the person they are referring to face to face. Your meeting is more than likely to only be 10-15 minutes long. If you cannot get a meeting with your GP, meet with their practice nurse or practice manager. Practice managers are often the people who will instigate change in a practice and often the person you actually need to talk to. Practice nurses who are trained in chronic care also provide the clinic with the ability to engage more effectively in exercise referrals. Keep the first contact brief as practices are bombarded with phone calls from other healthcare providers and pharmaceutical reps asking to visit. Your first contact will likely be through talking to the practice reception staff or practice manager over the phone. Briefly introduce yourself and say you would like to discuss your exercise physiology service with the doctors and practice nurses. First impressions count make sure to mention your specialty e.g. I d like to discuss exercise physiology services for your patients with heart disease/ diabetes/musculoskeletal etc. If possible, ask a colleague who is already known to the practice to introduce you. Make an appointment to visit the practice to discuss your service. If you want to see them you need to book a time that suits their schedule. Some practices will not make appointments and will ask you to just drop in sometime between certain hours of the day. This can mean sitting around the practice waiting room for a while until the GP has a free moment to see you, so take something to occupy your time!

PREPARING TO VISIT Once you have secured a meeting, you need to make the most of this time. Begin the meeting with your key messages and provide the GP/clinic with the ESSA I am an Accredited Exercise Physiologist flyer. You can download the flyer from the members section of the ESSA website under member resources. Most GPs understand the benefits of exercise. What you need to do is tell them what you can do, and how you will support their patients Give them one or two examples of clients you have treated, their condition and how exercise changed the markers for this condition (e.g. blood pressure, blood lipid profile, pain scale). Finally, let them know what your relationship with them will be, i.e. how you plan to work with them to improve their patients outcomes. Ensure that you have multiple copies of the I am an Accredited Exercise Physiologist flyer (with your contact details clearly visible on the front) available to hand out, enough for the GP/s but also extras as there may be practice nurses or support staff who might be interested as well. Take copies of any resources that you would like the practice to have e.g. brochures, posters, referral pads (see the list of available free resources on page 5). If you post any of these items they are more likely to be put on a shelf somewhere or thrown into the bin. Prepare, prepare, prepare. Rehearse what you would like to say to ensure that you maximise your time. Keep your information professional, clear and concise. Know your Medicare item numbers. A big drawcard for AEP services is that for some patients it can be covered entirely or partially by Medicare. GPs and practice nurses will be talking about different item numbers so it is important to know the item numbers than can be used as well as any other paperwork that is required. Be up to date on your clinical knowledge. You may be asked clinical questions particularly about the benefits of exercise for patients or how you would manage a patient with a comorbidity such as osteoarthritis. Take some detailed case studies with pre and post measurements to demonstrate how effective your service can be. Dress respectably. First impressions last and GPs/ practice staff may judge your program and your ability to deliver based on your physical appearance. ON THE DAY Quick one-on-one appointment with a GP or nurse You are likely to have only 10 minutes with the GP, nurse, or practice manager so you need to get your message across quickly and effectively. Rebates: AEP services are eligible for Medicare, DVA and private health rebates (get to know the relevant item numbers) Evidence: Exercise physiology enhances patient outcomesthrough evidence based practice competing for their attention. Take handouts, and make it as interactive as possible with quizzes, case studies and lots of opportunity for discussion. If you do have a lunchtime session make sure to take some food with you, maybe a sandwich platter from the local deli. Exercise is Medicine Australia has a 30 minute general presentation which may be used for these sessions. Contact info@exerciseismedicine.org.au for more information Resources: FREE resources available to support their practice Local: You service the area and are currently taking new clients Group session with GPs, nurses and other practice staff Group sessions are usually held in the tea room at lunchtime, with whichever clinicians are on break at the time. There may be people coming and going, so prepare to be interrupted and

INFORMATION Rebates Medicare Rebates: Medicare Australia provides the following initiatives that attract a Medicare rebate when the service has been provided by an accredited exercise physiologist. AREA item NUMBER** DESCRIPTION MBS BENEFIT (85%) Aboriginal Health Services 81315 Exercise Physiology Health Service $52.95 CDM 10953 TCA- Exercise Physiology $52.95 Type 2 diabetes 81110 Exercise Physiology Assessment for Group Services $67.90 Type 2 diabetes 81115 Exercise Physiology Group Services $16.95 **Each item number is described by a series of requirements that must be met by AEPs who provide these services. Before providing any services ensure you are familiar with the related items descriptors. Item descriptors can be viewed at MBSOnline by typing the item number into the search the MBS field or clicking the hyperlink above. AEPs are regularly audited by Medicare Australia to monitor service compliance. Failure to follow these item descriptors may result in a loss of provider eligibility or repayment of collected patient fees Department of Veterans Affairs: ITEM DESCRIPTION FEE NUMBER EP 10 Initial Consultation- Rooms EP 11 Subsequent Consultation- Rooms EP 12 Initial Consultation- Home EP 13 Subsequent Consultation- Home EP 14 EP 15 EP 16 EP 17 EP 18 EP 19 EP 20 EP 21 Initial Consultation- 1st patient- Public Hospital patients- Public Hospital Public Hospital Subsequent Consultation, 2nd and Subsequent patients - Public Hospital Initial Consultation- 1st patient- Private Hospital patients- Private Hospital Private Hospital Subsequent Consultation, 2nd and Subsequent patients - Private Hospital EP 22 EP 23 EP 24 EP 25 EP 26 EP 27 EP 28 EP 29 Initial Consultation- 1st patient- RACF High Care patients- RACF High Care RACF High Care Subsequent Consultation, 2nd and Subsequent patients - RACF High Care Initial Consultation- 1st patient- RACF Low Care patients- Low High Care RACF Low Care Subsequent Consultation, 2nd and Subsequent patients - RACF Low Care EP 30 Group Session $28.30 DVA Schedule of Fees is indexed yearly. Delivery of these services must be in accordance with the Notes for Allied Health Providers Section One- General and Section 2(f) for Exercise Physiologists. Descriptors relating to each item number can be found online at: http:// www.dva.gov.au/service_providers/fee_schedules/pages/dental_ and_allied_health.aspx

Private Health Funds: provided by accredited exercise physiologists. Rebates depend on the individual s level of cover. Evidence There is a growing evidence base for clinical exercise prescription. The ESSA Position Statements (available under member resources on the ESSA website) are a good place to start. Perhaps take one or two with you Free resources are available for download Visit both the EIM Australia website and also the ESSA website under member resources to print some of these to take along: 2014 Australian Physical Activity and Sedentary Behaviour Guidelines Adult pre-exercise screening tool Pre-exercise screening tool User Manual Exercise is Medicine Australia factsheets Health Care Provider Exercise is Medicine Action Guide Accredited Exercise Physiologist Scope of Practice Physical activity/ exercise referral pathway & forms Medicare Department of Veterans Affairs (DVA) WorkCover Exercise is Medicine brochure Indicators for physical activity and exercise Contraindications for physical activity and exercise Referrals to AEPs under Medicare Physical Activity Stage of Change: Assessment Tool Local contact: Make sure they know how to get in touch with you. Leave your business card behind. You may be able to leave some brochures of your practice for display in the waiting room. Remember to add your details to the ESSA I am an Accredited Exercise Physiologist flyer, and make sure your details are up to date in the ESSA Find an AEP search function. General tips: Once in with the GP or practice nurse give a brief outline of your services e.g. what your specialty is, what type of clients you see, what the expected outcomes are and how much it will cost. Try to be as succinct as possible. Show the GP the EIM Healthcare Provider Action Guide with the different referral pathways. Outline each referral option available highlighting the paperwork required and showing an example of the different forms required as you go. Explain that the GP will be informed of their patient s progress throughout the program. Give the GP any resources that you would like the practice to have e.g. posters, brochures. Ask if they have any questions about your clinic or referring. Leave your contact details including a website that they can go to for further information. Following up It is very important to make a follow up phone call to the GP approximately 1-2 weeks after your visit. Ask how they are going with the referral process and if they have any questions or problems. Invariably they will have only taken in about 1/3 of what you have explained at the practice visit and will need clarification on what the program is and how to refer. When you receive referrals, be sure to keep the referring clinician informed with detailed reports. One of the most important steps in building relationships with other health professionals is to keep them in the loop. GPs want feedback from health professionals regarding patient progress. It also reminds the GPs of your service each time they receive a report. GPs and practice nurses often say they hear that exercise works, but they do not see it working with their patients or know what treatment they are actually receiving. If a GP sees how exercise is helping their patients they are more likely to continue to refer. The cost of not writing a report equals a loss of referrals. The gain in taking an extra five minutes three times per patient to write a report equals a referral process. STEP 1 - Within 48 hours of seeing a referral patient, a letter/fax/ email should be sent to the referring professional acknowledging that you have seen their patient and provide a very brief description of your plans for their patient. STEP 2 - A follow-up letter/fax/email should be sent about 4-6 weeks into the treatment to provide the referrer with a brief update, i.e. patient A patient A has increased their knee extension range of movement by xx degrees, and 6 minute walking distance by xx metres. STEP 3 - A final letter/fax/email should be sent to notify the referring professional of the final status of the patient and what self-management plans are in place for the patient to continue with, i.e. their maintenance program. All reports to GPs should be no more than half a page and if possible, no more than five lines. Feedback suggests GPs prefer dot points and the information communicated as simple as possible. See the members area of the ESSA website under resources for report templates. Remember make sure GPs can find you. Are your details up to date in the ESSA Find an AEP search function? You can do this via the members area of the website. Explain what the GP needs to do with the completed paperwork i.e. fax or post the forms through to you and you will contact the patient to book them in for their initial assessment.

CASE STUDIES 1. An overweight patient with type 2 diabetes and high blood pressure After examining the patient s medical history, medications, and conducting a musculoskeletal assessment, the AEP will develop an integrated exercise and nutrition program to assist the patient to reduce body fat levels improve blood glucose control and reduce blood pressure. Regular exercise has been shown to reduce blood pressure by up to 10 mm Hg and significantly increase insulin sensitivity. An exercise program will be designed that takes into account any musculoskeletal or biomechanical concerns and the patient s current fitness level. This information will be used to determine the most appropriate exercise options. Nutritional advice may also be provided to assist the patient to achieve their health goals. The program may also include some supervised exercise sessions to ensure the patient is exercising at the appropriate intensity. Blood glucose levels may also be monitored before and after exercise to ensure the patient is exercising safely. 2. Recent coronary infarction requiring the implantation of a stent The AEP will review the patient s history and cardiologist s report (including any results of relevant cardiac investigations such as an exercise stress test) to assess the patient s current cardiac risk profile. The patient s exercise tolerance and medications will be reviewed to develop a safe and effective exercise program so as to improve exercise capacity and quality of life. Relevant advice on the optimal exercise type and intensity will be provided, and supervised exercise sessions will be conducted initially to ensure exercise safety and provide reassurance. Nutritional advice may also be provided to assist with any issues related to blood cholesterol and weight management. 3. A patient has chronic lower back pain, knee osteoarthritis after surgery, and an unstable shoulder. Following a definitive diagnosis of the back and shoulder pain, an AEP can design a specific exercise rehabilitation program that will strengthen and mobilise the musculoskeletal structures that support the joints,which may be contributing to the chronic pain cycle and reduce the re-occurrence of an injury. 4. A patient recently diagnosed with osteoporosis High intensity strength training and impact exercise have been shown to be effective in increasing muscle strength and maintaining or even increasing bone density by up to 2%/year, which will assist in reducing the risk of a fracture during a fall. An AEP can design and supervise a specifically focused strength and balance training program, so as to reduce the possibility of a premature fracture during falls. The AEP may also be able to advise on a nutrition program to maximise the gains in muscle and bone mass with exercise. 5. A patient recently diagnosed with chronic depression Regular exercise is now well recognised to reduce the symptoms associated with depressive illness. However, as these benefits are associated with high intensity weight training, it is important that exercise sessions are supervised by an AEP. The AEP can also assist with motivation and compliance of the program, which is an important support mechanism especially for patients with a mental illness. 6. A patient undergoing chemotherapy after being diagnosed with cancer. Regular exercise not only reduces the risk of developing cancer, but has also been shown to be an important component in the rehabilitation process to maintain fitness and quality of life. The AEP will consider the type of cancer concerned, any resulting functional impairment and the type of treatment being undertaken. As chemotherapy may lead to fatigue, compromised immune function and nausea, the AEP will be able to design a progressive exercise program that takes into consideration these concerns. The AEP will also work with your medical team to maximise the potential outcomes of the exercise program, while minimising any side effects. 7. A young male footballer has been undertaking a weight-training program for the past six months to increase his muscle mass, but he has not increased his weight. He also complains of being constantly fatigued after training The AEP will be able to closely examine the structure and progression of the patient s weight-training program to determine if it has been optimal to increase strength and muscle mass. The AEP will also provide advice on how the program may be restructured to achieve patient goals. By carefully examining the footballer s daily energy, protein and carbohydrate intake, and the timing of the food intake in relation to training, the exercise physiologist may also be able to provide advice on the cause of training fatigue and how to maximise muscle mass gains. The AEP will also work closely with the GP to determine if there are any nutrient deficiencies that also may be causing the fatigue.