Introduction by Croakey: On 2 August 2020, the Victorian Government declared a state of disaster in response to a jump in COVID-19 cases in the previous two months. The very next day, the COVID Positive Pathway was launched – a unique collaboration aiming to provide holistic care for adults able to isolate at home.
Developed during an intense three weeks of daily meetings between representatives from the Royal Melbourne Hospital, cohealth, and North Western Melbourne Primary Health Network, the Pathway is flagged in a recent analysis in The Medical Journal of Australia as an innovation that may be useful for managing other health conditions.
“Strategies for overcoming regulatory, legislative, and funding barriers to timely sharing of information and care delivery by primary care, hospital services and public health authorities should be further investigated,” says the MJA report.
Of 1,392 people referred to the Pathway between 3 August and 31 December 2020, 858 were eligible for enrolment, and 711 consented to participation; 647 (91 percent) remained in the Pathway until they had recovered and isolation was no longer required. A total of 575 participants (81 percent) received care in primary care, mostly from their usual general practitioners; 155 people (22 percent) received care from hospital outreach services, and 64 (nine percent) needed hospitalisation.
About one-third of participants required assistance with food and other basic supplies.
The authors below reflect on some of the lessons from their collaboration, including the importance of addressing the social determinants of health and “of non-healthcare supports in the management of infectious, or chronic, disease”.
Janelle Devereux, Seok Ming Lim and Nicole Allard write:
The banal definition of pandemic – “the worldwide spread of a new disease” – masks a much more complex reality.
Each pandemic is its own entity, with its own qualities, arising not only from the properties of the infective agent that produces the disease, but also the social, economic, technological and communications ecosystems in which it spreads.
The emergence of COVID-19 in Victoria in mid-2020 thus presented a unique set of challenges. SARS-CoV-2 was a highly transmissible virus, for which neither effective treatment nor vaccine existed. It was debilitating, sometimes lethal, and, as experience overseas amply demonstrated, had the ability to overwhelm medical systems very quickly.
Without vaccine mitigation available – as is the case with influenza, for example – it was clear that the health sector needed to adopt a novel approach to caring for infected people and limiting transmission.
Even with a new disease vector, however, some elements remain sadly predictable. Melbourne’s northern and western suburbs contain large numbers of economically disadvantaged residents, many of whom work in multiple insecure jobs. It has long been recognised that the combination of high mobility and low incomes is a key driver for infectious diseases.
It is also well established that insecure and casual employment makes it much harder for infected individuals to isolate for the period necessary to prevent transmission.
It came as no surprise, then, that early case spikes were seen in these districts. The need for an effective response sparked a unique and rapid collaboration between local health services. Initially, the working group comprised The Royal Melbourne Hospital, North Western Melbourne Primary Health Network (NWMPHN) and community health organisation, cohealth. A little later they were joined by organisations such as Western Health and Werribee Mercy Services as well as general practitioners across the region.
The result of this cooperative approach became known as the COVID Positive Pathway. It established a set of protocols that, very quickly, was adopted and adapted across Victoria.
Its creation, significance and effectiveness have now been recognised in the form of a major paper published in The Medical Journal of Australia.
Playing to strengths
Although the COVID-19 picture has changed dramatically since the Pathway was launched in August 2020, the protocols have proven robust. Pathway models are now being explored as methods of managing other chronic conditions, including long COVID, heart and lung disease, and mental health.
Arguably the key principle that governed the design of the first Pathway was the firm belief that healthcare provision is not a competitive sport. It was critical to forge an integrated system that was person-focussed, and overrode the challenges associated with competing priorities and funding agendas driven by different levels of government.
By setting these matters aside, it was remarkable how quickly the model was developed, and how, as other health organisations brought in additional capacity, it could be continuously improved. The keys were making sure that tertiary health, primary health and community care systems all played to their strengths – by prioritising patient welfare at all times.
Initial triage by cohealth made sure that, where necessary, financial and psycho-social supports were put in place, which meant that patients isolating at home could do so with personal distress levels minimised. This social determinant approach enabled patients to stay well, but also to stay connected with their families and community.
Through NWMPHN, GPs were placed at the forefront of managing patients with mild symptoms – the majority of people affected. Allocated general practitioners checked in with home-bound patients, remotely, every two days, monitored condition, advised on symptom control, and, if necessary, initiated rapid escalation of treatment if health deteriorated.
The hospitals were thus able to focus on moderate and serious cases, with spontaneous emergency department presentations kept to a minimum.
The success of the first COVID Positive Pathway was demonstrated not only by its own performance but also by the fact that it proved easily adaptable across other urban, regional and rural areas. Subsequent coronavirus variants certainly placed the health ecosystem under severe strain, but the model continued, and continues, to serve as a critical scaffold.
An important element of the collaborative approach was that it produced fresh, clear insight into the community and its needs. While every element of this view had previously been visible to at least one part of the health sector, it was only through the interaction necessitated by the Pathway approach that the individual observations became integrated into a whole vision.
And this is important, because it informs the future applications of the model – potentially in health fields superficially far removed from the coronavirus response.
The realisation that high proportions of Pathway participants needed culturally specific, financial and logistic assistance to successfully isolate adds to a growing evidence base around the importance of non-healthcare supports in the management of infectious, or chronic, disease.
Put bluntly: it is of little value offering world class disease treatments if the patient cannot safely access them without risking income or family and cultural coherence.
The Pathway model shows significant potential for the mitigation and management of other infectious epidemic (or pandemic) diseases such as influenza. It also can be adapted for dealing with certain chronic noncommunicable diseases – as well, of course, with future variants of COVID-19.
For this to happen it is critical that in all cases importance is given to joint clinical and operational governance, established and trusted relationships, clear roles, responsibilities and pathways and access to data and insight about the people most at risk.
And that requires investment, guarantees and good faith – once again, extending across health care strata and funding sources.
Primary care spending, for instance, particularly preventive care spending, is still too little. The frontline nature of primary care needs to be acknowledged and to become part of disease response planning. GPs and community health practitioners need to be better resourced to work with marginalised communities and have a population approach to best care delivery.
We all want good hospital care but most of us would prefer a good GP, best practice care in our homes and community, and to not need a hospital visit at all.
The aim of Australia’s first COVID Positive Pathway was to provide universal care. This was a big ask in the rapidly evolving and understandably chaotic environment of the first coronavirus wave, but nevertheless it was successful in capturing and treating 83 per cent of diagnosed eligible people.
One day the coronavirus pandemic will recede. With proper support, however, the Pathway it spawned will remain, improving access to care in more ways than its architects imagined.
L to R: Janelle Devereux, North Western Melbourne Primary Health Network; Dr Seok Ming Lim, The Royal Melbourne Hospital, University of Melbourne; Dr Nicole Allard, GP at cohealth
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