How the Pathway model took pressure off Vic hospitals

In mid-2020, faced with a rising wave of COVID-19 infections — a previously unknown disease with neither vaccine nor effective treatment — an urgent, improvised collaboration between a Melbourne hospital, a primary health network and a community health organisation created a system that supported thousands of lives and ensured the city’s healthcare ecosystem didn’t collapse.

The multidimensional constructed model, which included financial, social and mental health supports, resulted in more than 80% of COVID-19 patients being treated successfully in their own homes, monitored by GPs, leaving hospitals free to care for the seriously ill.

Dubbed the West Metro COVID-Positive Pathway, the model was quickly adapted by other health services and is now the standard tool for pandemic management across Victoria. In a paper published online in the Medical Journal of Australia, a team of experts led by its architects say the pathway approach can now be adapted to improve management of other infectious or chronic diseases.

“The Pathway was originally designed by North Western Melbourne Primary Health Network (NWMPHN), the Royal Melbourne Hospital (RMH), and community health organisation cohealth, supported by the Victorian Department of Health,” explained co-author Janelle Devereux, NWMPHN’s Executive Director for Health System Integration.

“It went into operation on August 3, 2020, as the state government declared a state of disaster. A month later, three more hospitals joined in — Djerriwarrh Health Services, Western Health and Werribee Mercy Hospital. By that stage the Pathway covered seven municipalities containing more than one million people.”

What made the Pathway design effective for patient care and resource allocation was that it embraced three clinical skill sets.

“The prototype design took into account the different resources and specialist knowledge of each Pathway partner — utilising hospitals for acute medical care, NWMPHN’s local knowledge of the primary health landscape within the region, and cohealth and community health partners’ skills in caring for people isolating at home,” said lead author Dr Seok Lim, a geriatrician and general medicine physician at Royal Melbourne Hospital.

“Design of the prototype was also based on meeting the needs of people with COVID-19, both in the clinical domain of health monitoring — especially rapidly detecting and responding to deterioration — as well as the mental health and practical aspects associated with home isolation.”

From its inception, the Pathway model operated as an inclusive, multipronged process. Entry point for patients was a positive PCR result, followed by a contact-tracing phone call. If the patient consented, cohealth community health workers conducted a standardised risk assessment for severe disease and any psychosocial problems that might preclude home-based isolation.

How the Pathway model took pressure off Vic hospitals

People with financial problems or other challenges such as drug and alcohol dependencies were referred for specialised support, as was anyone without a Medicare card.

“In the design and delivery of the program, cohealth and partners recognised the importance of incorporating social and mental health supports for people in our area,” said co-author, cohealth’s COVID-19 clinical lead, Dr Nicole Allard.

“We developed a model that supported the complex needs of people who were isolating at home for 14 days, valued the expertise of GPs in our area and aimed to have appropriate referral to hospital services. Our teams were able to assist with complex care navigation — meeting people’s health needs beyond COVID-19, and social support for them to stay at home safely.”

Following triage, enrolled participants were allocated to low, medium or high tiers of care according to their symptoms and risk factors for severe disease. Low-risk participants were monitored by telehealth services (most provided by regular GPs) every second day during the second week of illness.

People at risk of severe disease and those with moderate symptoms were referred to hospital outreach services. Those already seriously ill were placed in wards or ICU.

“Despite rapidly rising numbers of infections, the Pathway ensured all patients were monitored and provided with best-case care,” said Christopher Carter, NWMPHN CEO.

“Other countries saw their hospital systems overwhelmed during coronavirus waves. The Pathway model which we and our partners devised stopped that happening here during the first wave of the pandemic, while simultaneously ensuring optimal care for all patients.”

As well as being adopted as the standard model across Victoria, the model is set to be adapted to manage other conditions.

“Heart disease and lung disease are good examples,” Dr Lim said. “Royal Melbourne Hospital and NWMPHN are currently working together on a project for these conditions that borrows many principles of the Pathway model of care.”

The MJA paper was written by a team of 14 experts, including Royal Melbourne Hospital respiratory physician Dr Alistair Miller, Professor Benjamin Cowie from the Peter Doherty Institute for Infection and Immunity, and others from the WHO Collaborating Centre for Viral Hepatitis, Djerriwarrh Health Services, Western Health, Werribee Mercy Hospital and Vrije Universiteit Amsterdam.

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