Integrated Primary Care Paramedicine on Aotea Great Barrier Island

Aotea Great Barrier is a remote island located 90km off the coast of Auckland with a resident population of around 1,250 people, not including the many holiday-home owners or tourists that travel to and from the island each year.

Many of the services that people on the mainland or in urban areas take for granted are simply not available in remote communities. There is no formal district nursing service, no rest-home or private hospital, and a single provider of limited home help support.

Primary and urgent care services are provided by Aotea Health, who operate two clinics on the island and provide a PRIME and after-hours urgent care response to the community. The local Hato Hone St John ambulance on the island struggles to recruit and retain enough volunteers to maintain 24/7 cover.

Fast forward to 2024, and Comprehensive Primary and Community Care Teams (CPCT) funding has enabled a local paramedic to be employed part-time to support the needs of the island's health centres, primary care team, and the community.

A hybrid model is now operating, where the local paramedic responds in the ambulance to deliver primary care in the home rather than just being solely focusing on emergency response.

"The role is incredibly varied", explains local CPCT Paramedic Adam Johnston. "Some days I feel like I'm a cross between a district nurse, clinical educator, counsellor, rest home nurse, pharmacist assistant, lab technician, paramedic, medical alarm installer, social worker and general fix-it guy".

Adam is quick to point out the benefits of having such an integrated primary care role that connects in with others in the wider primary health care team.

"You really become the ambulance at the top of the cliff, rather than at the bottom of it. It really is about keeping people well so that they don't have a preventable trip to hospital".

With the remote location, trips to hospital are expensive, both in terms of air ambulance transfers and additional healthcare burden, but also expensive for the patient in terms of logistics, access to social and family support, and the cost of a return flight home.

Adam reflects on a case where he responded in the ambulance to a collapsed patient. Neither he or the responding PRIME GP knew the patient, but he was able to access the practice management system and patient records remotely using the ambulance computer to gain vital medical history at the scene. He then transported the patient to the local health centre, where he then continued providing point of care testing, treatment, and appropriate referral to hospital. He then saw the patient at a follow-up clinic appointment and was able to problem-solve the reason behind the ongoing syncopal (fainting) episodes. A few tweaks of medicines and diet in consultation with the GP meant that the patient's ongoing medical problem was managed and they had no further fainting spells.

"The lines are really blurred out here now", says Adam. "Paramedic care no longer stops at the door of the health centre. I now work inside the health centre, on the ambulance, and in people's homes providing a mix of primary, urgent and emergency care".

Being the one-stop-shop for everything 'ambulance' on the island, he grabs opportunities to improve health outcomes wherever he can. While installing or upgrading a medical alarm for an elderly patient, he may also conduct a general health exam that may include things such as a COPD review, falls risk assessment, medication review, mental health review, or social review. Any emergency calls attended provide an opportunity for future follow-up visits to address any preventable issues.

"The housing situation can be pretty grim on the island, with elderly folk living in off-grid properties sometimes with no heating and no insulation, or no hot water, and with complex medical conditions or immobility", he explains. "I get to see how people are living and surviving and coping in their homes, which is something that you can't really assess properly in a 15 minute clinic consultation".

He points out that he has treated three people for hypothermia in the past two months, two of these cases he discovered inadvertently while doing home visits for routine dressing changes.

He also often helps patients to sort their medicines out, as various combinations of blister packs and tablets can accumulate in the home as patients have their medicines changed.

"I regularly find patients are taking the wrong medicines, the wrong doses, or are missing the correct medicines, or just don't understand why they should be taking some of their pills".

He says that when patients are on so many medications, they can get confused over what they should be taking, and if they are acutely unwell, this problem can worsen. This often involves him liaising with the island pharmacy and prescribing clinicians to ensure patients are receiving what they should be, as well as educating patients at home, and if needed, disposing of surplus or incorrect medications to prevent future errors.

Sometimes the role and treatment gets very 'left-field', like climbing on water tanks to dose them with chlorine when his housebound patient had rampant diarrhea, or organising the installation of a new wood stove for a wheel-chair bound patient who had a broken fireplace that was spewing lethal fumes into the house to the point that the ceiling was coated black with soot.

"The other day I organised for a technician to come a repair the aerial for a diabetic patient with cellulitis and depression. I had sorted his blood tests, IV and oral antibiotics, insulin and diet, but his only pleasure in life at the moment was his TV and it wasn't getting a signal".

"If I don't do these simple extra steps for patients, they just don't get done, and they are all contributing factors to the patient's health situation".

Just recently he was running an education session for local kaumatua how to use an AED that has been installed on the marae.

"This was an opportunity to create and build up relationships and trust, plus an opportunity to potentially save a life in the future", says Adam, acknowledging the poor statistics with regard to timely and appropriate access to healthcare for Māori in this country. "Hopefully education and a familiar face can help to reduce some of the barriers to people seeking help or accessing health services when they need it".

"I really see this level of integration as being a good way forward for primary healthcare in this country", says Adam. "It feels proactive rather than reactive, and is providing positive outcomes for patients and cost savings in the form of prevented hospital admissions, as well as taking some of the workload burden off busy GPs, NPs and rural nurses".

 

Aotea Health is part of Auckland PHO, who is taking part in the Comprehensive Primary and Community Care Teams (CPCT) programme.

About CPCT:

The Comprehensive Primary Care Team (CPCT) programme is sponsored by Te Whatu Ora. It launched this year in general practices as a way to enhance preventative and proactive approaches to supporting patients and help increase the capacity of the stretched workforce to be more responsive to health needs.

Roles included in this programme are:
• Clinical pharmacists
• Care coordinators
• Physiotherapists
• Extended care paramedics.

 

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