Feet First: Taking foot care to the bush

Aim

To provide rural consumers with equitable timely access to foot screening and foot care services in the Townsville Hospital and Health Service (THHS).

Benefits

• increased foot screening in rural facilities to identify foot problems
• clear escalation referral pathways to THHS podiatrists
• increased capacity in podiatry workforce to deliver telehealth consultations to rural consumers
• reduced travel required for rural consumers without compromising standard of care
• upskilling of AHAs trained in podiatry delegations
• increased awareness of podiatry referral pathways, core business and services available

Background

In 2018-2019 new recurrent funding was provided to Queensland HHSs to expand ambulatory high risk foot services statewide. This supported new podiatry positions and a sustainable workforce model placing podiatry staff for the first time at the Townsville University Hospital campus.

The recurrent funding saw each HHS report against key performance indicators (KPI) in 2020 to “assess, treat and initiate a care plan for 80% of new foot ulcer or acute Charcot arthropathy patients within the best practice timeframe of two working days from receipt of referral”.

Reporting to the KPIs saw a trend of rural patients declining appointment within 48 hours faced with the geographical barrier of travel, often reliant on organising community transport to attend. THHS podiatrists did not feel confident in providing initial telehealth appointments for these patients with no existing booking process or format to follow.

The Feet First project provided an opportunity to develop a new delegation model of care to improve access to foot screening and foot care in the THHS. Patients identified as acute risk were offered 48 hour telehealth appointments to provide equitable timely care and clinicians were upskilled to deliver effective assessment and treatment via the platform.

The model aimed to provide access to the right care at the right time to improve the patient journey and increase efficiency within the resources available (National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes, 2011)

Discussion

The THHS arranged for 14 AHA/IHW staff to be trained in the foot screening and low risk nail care delegations. The model of care was trialled over three-month timeline during which 135 foot screenings were performed. Foot screening was prioritised for the following at risk populations:

• Diabetes diagnosis
• Chronic Kidney Disease, or Renal Dialysis
• Over the age of 65.

Between 5-13% of inpatients screened were of acute risk with 50% seen by the podiatrist via telehealth within 48 hours of referral. The other 25% declined a telehealth review travelling to Townsville to attend a face to face podiatry appointment. The following 25% were transferred to Townsville under the care of surgical teams.

On average it was seen that foot screening takes 4-12 minutes per patient irrespective of their foot risk status and there was no significant difference between the amount of time taken to complete the screen when comparing a podiatrist and an AHA.

The model of care delivers an efficient use of resources with no travel costs associated with the AHA and IHW delivering the foot screening with increased access for patients to the service.

Five of the six implementation sites saw successful sustainable implementation of the model of care with future provisions of integrating outpatient delegated foot care clinics.

Patients of low risk who received low risk nail care during their inpatient stay reported it was “fantastic to have the service available”, while patients involved in the telehealth sessions commented on the benefit of ‘tuning in to the podiatrists” and felt that there was no compromise in the service delivered.

AHAs involved in the Feet First project reported feeling supported in both the training and the model of care delegations with supervision provided by the podiatrists online. This facilitated the use of technology to provide ongoing support in both group and individual sessions.

The project saw the integration of telehealth into the THHS podiatry model of care however further support is required to embed the use of telehealth into standard podiatry care at any stage of the patient journey.

Lessons learnt

The success of our project was limited with majority of the population screened situated in the inpatient setting while many patients reported that their foot wounds were managed by GP clinics and public outpatient nursing clinics prior to being referred to podiatry.

Integration of foot screening in the community setting is vital to identify foot ulcerations and refer them to high risk foot services. Further integration of AHA/IHW into nursing and telehealth streams is needed to improve the patient journey. Without the integration of these positions in with the nursing service many referrals are missed leading to representations to hospital.

Change in workplace culture is required to advocate that public podiatrists should be referred all foot ulcerations in the THHS for assessment. Ongoing nursing education is required for rural nursing services in both indications for podiatry referral and evidence-based management of acute foot disease.

Rural and remote sites continue to face the challenges of staff vacancies. During the project the THHS had two AHA positions advertised. The challenge of linking into these sites once vacant proved challenging. The importance of providing podiatry delegated training to new rural staff has been identified by THHS podiatry.

The uptake of telehealth is limited in the podiatry workforce with concerns regarding how to deliver care over the online platform. Ongoing support is required to see sustainable implementation of telehealth into podiatry model of care.

References

Queensland Health. (2020). Healthcare Purchasing: Ambulatory High Risk Foot Services. Queensland Health.

(2011). National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne, Australia.

Further Reading

PODIATRY LEARNER GUIDE: Assist with basic foot hygiene (health.qld.gov.au)

Clinical Task Instructions | Queensland Health

Supervision and delegation framework for allied health assistants (sarrah.org.au)