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Background and context The transgender community experiences high levels of mental distress. In the Canterbury region of New Zealand, transgender care was fragmented and there were gaps in service provision.Assessment of problem In 2019, a working group co-designed a model to coordinate and improve health care for the Canterbury transgender community. Their aim was to co-design and implement a comprehensive system for transgender health care that filled any existing gaps.Results A need was identified for support in the community for transgender patients with mild to moderate mental health needs who did not meet the threshold for referral to secondary care.Strategies for improvement Psychological packages of care were put in place in the community for transgender patients with mental health needs. In the first 9 months of the initiative, 85 patients received a package of care.Lessons This community-based model was well received by the community. Data analysis did not demonstrate a statistically significant reduction in depression and anxiety, but it did show a significant reduction in stress. Some further improvement opportunities existed, including shifting to a peer worker model and changing the evaluation tool.

ABSTRACT INTRODUCTION The HealthPathways programme is an online health information system used mainly in primary health care to promote a consistent and integrated approach to patient care. AIM The aim of this study is to perform a scoping review of the methodologies used in published impact and outcomes evaluations of HealthPathways programmes. METHODS The review included qualitative, quantitative or mixed-methods evaluations of the impact or outcome of HealthPathways. MEDLINE, Embase, CINAHL and Web of Science databases were searched. Seven programme aims were identified in the impact and outcome evaluation: (1) increased awareness and use of HealthPathways; (2) general practitioners are supported to adopt best practice, patient-centred care; (3) increased appropriate use of resources and services; (4) improved quality of referrals; (5) enhanced consistent care and management of health conditions; (6) improved patient journeys through the local health system; and (7) reduction in health-care cost and increased value for money. RESULTS Twenty-one studies were included in the final review; 15 were research papers and six were reports. ‘Increased awareness and use of HealthPathways’ was the most frequent programme aim evaluated (n = 12). Quantitative and qualitative research methodologies, as well as prospective and retrospective data collections, have been adopted to evaluate the impact and outcome of HealthPathways. DISCUSSION Assessing the impacts and outcomes of HealthPathways may be challenging due to limitations in primary data and the interconnectedness of change across the measured aims. Each aim may therefore require specific methodologies sensitive enough to capture the impact that HealthPathways are making over time.

Introduction: HealthPathways is a clinical information portal developed in New Zealand that enables general practitioners to manage and refer their patients in a local context. We analyzed specialist outpatient appointment costs in Mackay, Queensland before and after HealthPathways implementation. Methods: We retrospectively examined specialist outpatient costs for patients referred by Mackay general practitioners for conditions with varying levels of HealthPathways implementation. Ranked from most clinical pathways available to none, chronic diabetes, cardiology, respiratory, and urology visits from January to March 2015, pre-pathways, and January to March 2017, post-pathways, were assessed. Monte Carlo simulation was used to estimate cost changes. Per-visit costs were multiplied by visit numbers to estimate policy impact. Results: The mean cost per visit increased from $220 to $305 for diabetes and $270 to $323 for respiratory, and decreased from $296 to $257 for cardiology and $444 to $293 for urology. The policy impact for each disease group over 3, months after accounting for visit numbers was a likely saving of $30,360 for diabetes and $10,270 for cardiology, and a likely cost increase of $24,449 for respiratory and $20,536 for urology. Conclusions: We observed that conditions with more comprehensive clinical pathways cost Mackay HHS substantially less following implementation. Costs for low and no pathway implementation referrals increased slightly over the same period.

In 2008, Canterbury was delivering traditional hospital-centric care, with a weak primary-secondary interface. This did not meet the needs of the population, was financially unsustainable, and was adversely affecting patient care.

A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.

Aims • To determine if the HealthPathways site conforms with current best practice guidelines and health literacy principles. • To assess if the pathways are aligned with the World Health Organisation (WHO)’s principles of integrated care. • To determine if the referral and patient information on HealthPathways site is inclusive, i.e., where possible tailored to vulnerable populations (ATSI, LGBTIQ, CALD and PWD) and different age groups. • To determine if the HealthPathways site is user-friendly

INTRODUCTION Unmet needs are a key indicator of the success of a health system. Clinicians and funders in Christchurch, Canterbury, New Zealand were concerned that unmet health need was hidden. AIM The aim of this survey was to estimate the proportion of patients attending general practice who were unable to access clinically indicated referred services. METHODS The survey used a novel method to estimate unserviced health needs. General practitioners (GPs, n = 54) asked their patients (n = 2135) during a consultation about any health needs requiring a referred service. If both agreed that a service was potentially beneficial and not available, this was documented on an e-referral system for review. The outcomes of actual referrals were also reviewed. RESULTS The patient group was broadly representative of the Canterbury population, but over-sampled female and middle-aged people and under-sampled Māori. Data adjusted to regional demographics showed that 3.6% of patients had a GP-confirmed unserviced health need. Elective orthopaedic surgery, general surgery and mental health were areas of greatest need. Unserviced health needs were significantly (P ≤ 0.05) associated with greater deprivation, middle-age, and receiving high health-use subsidies. DISCUSSION To our knowledge, this is the first survey of GP and patient agreement on unserviced referred health needs. Measuring unserviced health needs in this way is directly relevant to service planning because the gaps identified reflect clinically indicated services that patients want and need. The survey method is an improvement on declined referral rates as a measure of need. Key factors in the method were using a patient-initiated GP consultation and an e-referral system to collect data.

This evaluation has explored the value of the Murray HealthPathways program against its objectives and, in particular, to explore the value of the HealthPathways program in: informing, guiding and supporting health professional practice; improving the experience and outcomes of patients and carers; and enabling health system improvement. The evaluation has also sought to inform the potential future directions for Murray HealthPathways. The evaluation process has taken place over a six-week period and has analysed data from existing sources, as well as captured new data from individual and group interviews, an online survey distributed to clinicians across the Murray PHN region and through the development of case studies illustrating key dimensions of the program and its impact. The limited scope and timeframe for the evaluation has meant that some key dimensions that would be ideal to measure were not able to be fully explored. This particularly relates to the value of the program relative to the investment of resources. The evidence that has been gathered and the conclusions that are strongly supported by those sources, however, show a program that is highly valued and valuable, and that delivers on all its objectives, either fully or partly. Great potential is seen in Murray HealthPathways as a resource now that supports, informs and guides health professionals in their practice and contributes to quality, appropriate and efficient care. In this report, the evaluation methods are described and the findings from each core method presented.

This project was implemented to identify and develop clinical HealthPathways to assist in the health management of children, adolescents and adults on the autism spectrum. HealthPathways is a web-based health information site, developed by Streamliners NZ. It helps clinicians, mainly general practitioners (GPs) to guide patients through the health system with clear referral pathways for their local area. The Autism HealthPathways were originally scoped and designed specifically for the Mackay Hospital and Health Service region with the long-term intention to share content across the national and international HealthPathways community. To achieve this outcome the project team needed to: understand the barriers and enablers to the provision of health care to children, adolescents and adults on the spectrum develop and implement evidence-based clinical care pathways for children/adolescents and adults on the spectrum evaluate health professional satisfaction with the pathway. As a result of this research the team developed autism-related content in nine HealthPathways to support the assessment and clinical care of children and adults across the lifespan. Pathways cover autism assessment and support, intellectual disability, developmental concerns, and mental health conditions, with a particular focus on post-diagnosis supports. Autism HealthPathways are now available for adoption and adaptation in 43 health regions, caring for more than 28 million people across Australia, New Zealand and the United Kingdom. To find out more about adapting or adopting Autism HealthPathways for your region, contact your local HealthPathways team directly via the HealthPathways Community website.

Clinical guidelines are recommendations targeted at medical professionals which aim to optimise patient care. When successfully implemented, clinical guidelines have been shown to improve processes of care and clinical outcomes. However, clinical guidelines are often not successfully implemented and there exists a significant variation in rates of compliance between different doctors. Factors which affect compliance fall in to four categories: patient, doctor, environment and guideline. In 2015 the Canterbury District Health Board changed to a new platform of online clinical guidance called Hospital HealthPathways. This platform differed significantly from its predecessor The Blue Book in both the development process and design of the clinical guidance. This study compared the use of and compliance with guideline recommendations between these two different platforms of clinical guidance. By doing so, this study was able to examine how guideline use and compliance is affected by the development process and design of a clinical guideline. Sub-group analysis examined how compliance varied between different clinicians, different patients, and different environments and also the interaction between these factors and guideline design. A sub-analysis examined barriers to guideline compliance reported by clinicians to understand the perceived obstacles clinicians had to following guideline recommendations. Finally, this study developed the concept of “appropriate non-compliance” by quantifying and describing cases where it was appropriate for clinicians not to follow local clinical guideline recommendations whilst managing patients.

HealthPathways (HPW) is an online health information portal which provides general practitioners (GPs), guidance on the assessment, management and referral of a range of conditions linked to local resources. However, there is a lack of understanding of the acceptance of pathways within primary health. The paper aims to discuss this issue. Design/methodology/approach This qualitative study identified baseline factors that promote the successful implementation of HPW in a major local health district (LHD) in Australia. The development, implementation and acceptance of Diabetes HPW were evaluated. A total of 16 semi-structured interviews were conducted with 12 stakeholders and 4 GPs. Interviews were digitally recorded, transcribed and analyzed qualitatively using a thematic analysis approach. Findings Four major themes were identified that promote the integration of care in the region through utilizing HPW: engagement, sustainability, transparency and accountability. Several factors identified as “enablers” or “barriers” are described at micro and macro levels of the healthcare system. Originality/value By combining the perspectives of both stakeholders and end-users, this qualitative evaluation of the localized HPW has identified relational and structural factors that promote the successful implementation of HPW to facilitate the integration of care in this LHD. Furthermore, this study provides other implementers with a comprehensive evaluation of the HPW development.

ABSTRACT Background and context General practice teams frequently request orthopaedic and musculoskeletal physiotherapy. In the Canterbury District Health Board (DHB) region, before November 2018, the criteria for DHB-funded physiotherapy were unclear. Wait times were many months. Care was provided on hospital sites. Limited data were available about the service. Assessment of problem A clinical project group including private and DHB hospital physiotherapists and general practitioners was established. Patients requiring orthopaedic and musculoskeletal physiotherapy who had certain criteria were seen by physiotherapists in contracted private clinics in the community instead of by physiotherapists in hospital departments. Patients received up to NZ$300 (excluding GST) of care. A claiming process was established that required the physiotherapy clinics to provide data on patient outcomes. Results In the first 12 months of the programme, 1229 requests were accepted. Patients waited an average of 11.1 days for their first appointment. There was an average Patient Specific Functional Scale increase of 3.7 after treatment. Strategies for improvement A change environment was critical for this community-based, geographically distributed model to succeed. It was supported by key clinicians and funders with sufficient authority to make changes as required. It required ongoing clinical oversight and operational support. Lessons DHB orthopaedic and musculoskeletal physiotherapy can be moved from hospital sites to a community-based, distributed service in a timely, effective and equitable fashion. There was a prompt time to treatment. Data collection was improved by tracking ‘before’ and ‘after’ measures.

AIM: To evaluate prospectively a clinical pathway for investigation of haematuria that involves an initial screening using a urinary biomarker of bladder cancer (Cxbladder Triage™ (CxbT)) in combination with either a renal ultrasound or a computed tomography imaging. Only test-positive patients are referred for specialist assessment and flexible cystoscopy. METHODS: The clinical outcomes of 884 patients with haematuria who presented to their general practitioner were reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, specialist assessment and histology. RESULTS: Forty-eight transitional cell carcinomas (TCC) and three small cell carcinomas were diagnosed in the study cohort. The clinical pathway missed a solitary, small, low-risk TCC. When combined, imaging and CxbT had a sensitivity of 98.1% and a negative predictive value of 99.9% to detect a bladder cancer. Follow-up for a median of 21 months showed no further new cases of bladder cancer had occurred in the patient cohort. Review of all new bladder cancers diagnosed in the 15 months following the study showed that none had been missed by haematuria assessment using the clinical pathway. CONCLUSIONS: The combination of CxbT and imaging reliably identifies patients with haematuria who can be managed safely in primary care without the need for a secondary care referral and a flexible cystoscopy.

BACKGROUND AND CONTEXT Frozen shoulder is a painful condition that follows a protracted clinical course. We aim to review the management of patients with a diagnosis of frozen shoulder who are referred for specialist orthopaedic evaluation against existing guidelines in primary care. ASSESSMENT OF PROBLEM Referrals and clinical records were reviewed for all patients referred for orthopaedic specialist assessment who received a specialist diagnosis of frozen shoulder. Diagnostic, investigation and management practices from a regional primary health care setting in New Zealand were compared with guideline-recommended management. RESULTS Eighty patients with frozen shoulder were referred for orthopaedic evaluation in the 13 month study period, mostly from general practice. Fifteen patients (19%) were identified as having a frozen shoulder in their medical referral. Most (99%) had received previous imaging. Seven patients (12%) had received guideline recommended treatment. STRATEGIES FOR IMPROVEMENT Education of all clinicians involved in patient management is important to ensure an understanding of the long natural history of frozen shoulder and provide reassurance that outcomes are generally excellent. HealthPathways now include more information regarding diagnosis, imaging and evidence-based management for frozen shoulder. LESSONS Frozen shoulder may be under-diagnosed among patients referred for orthopaedic review. Ultrasound imaging is commonly used and may identify occult and unrelated pathology in this age-group. When managed according to clinical guidelines, patients report significant clinical and functional improvement with most reporting 80% function compared with normal after 1 year. KEYWORDS Adhesive capsulitis; bursitis; injections; practice guideline; primary health care; ultrasound.

The goal of the study has been to explore, learn and bring back relevant findings on how to – and how not to – use incentives and levers for digitising and integrating primary care and recommend ways for the NHS to apply these lessons. The health systems studied in person and in detail are those of New Zealand, Australia and the US State of California. Meetings involved academics, clinicians, healthcare system managers and policy professionals, payers, providers of primary and hospital care, professional bodies, industry representative bodies, the tech industry itself – both tech entrepreneurs and global corporations, think tanks, financiers.

HealthPathways is a web-based clinical information portal containing best practice, evidence-based information aimed at improving the effective integration of primary and acute healthcare services and limiting clinical variation. In Western Sydney, HealthPathways is based on a three-way partnership between WentWest (Western Sydney Primary Health Network), Western Sydney Local Health District (LHD) and Sydney Children’s Hospital Network Westmead (SCHN Westmead). By 30 April 2016, 225 pathways had been developed locally by clinicians from the primary and acute care sectors working together. The Phase 1 evaluation approach reported here was developed with the following aims: 1) Identify drivers for change that can be facilitated by the HealthPathways initiative in Western Sydney. 2) Document the models used in developing Western Sydney HealthPathways to April 2016, including the process for selecting pathways for development. 3) Examine the effectiveness of current HealthPathways processes 4) Identify areas for future improvement and investigation

The John Hunter Hospital (JHH) is a tertiary referral public hospital located in Newcastle, New South Wales and is a facility of the Hunter New England Local Health District (HNE LHD). The Antenatal Clinics in JHH receive around 3,500 referrals each year for women at all levels of risk related to their pregnancy. The JHH Maternity service was one of the first specialist services to participate in the HealthPathways process. In collaboration with General Practice, the JHH Maternity service developed a suite of 17 HealthPathways including the Routine Antenatal Care HealthPathway.

One in five people will experience persistent pain in their lifetime. People who experience persistent pain access healthcare services more frequently and this places a great burden on the Australian economy, costing $34 billion a year. Persistent pain is 4% of all chronic problems managed by General Practitioners (GPs) which equates to around 74,000 persistent pain patient problems managed by GPs in 2013 in the Hunter Medicare Local (HML) region. The Hunter Integrated Pain Service (HIPS) offers specialist pain management support in the Hunter New England Local Health District (HNE LHD). HIPS was one of the first specialist teams that requested to be a part of the Hunter & New England (H&NE) HealthPathways process.