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Podiatrists are unable to refer to High Risk Foot Clinics

Discussion in 'Australia' started by surfboy, Oct 11, 2014.

  1. surfboy

    surfboy Active Member

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    Hi folks,

    I would be pleased if somebody can please tell me why it is the case, that Podiatrists are unable to directly refer patients for care and assessment at an outpatient-based high risk foot clinic.

    Countless times, including last week the latest, I have encountered a patient with acute diabetic ulceration that would benefit from care at a high risk foot clinic. It is bizarre, but the Podiatrist and staff at the High Risk Foot Clinic continually advises me that they will not accept any referral for intake from a Podiatrist, stating to me that the GP must make the referral.

    So again last week I phoned the GP, with the GP questioning why I as the podiatrist was not making the referral. He asked, with good reason, why I could not provide the referral as I was the primary practitioner involved in the patient's foot care.

    Surely it is a waste of time and resources for Podiatrists to be barred from making such direct referrals ourselves as foot care experts?! - Personally I find it offensive.!
  2. markjohconley

    markjohconley Well-Known Member

    Ridiculous, what state?
  3. surfboy

    surfboy Active Member

    Thanks yes it's happening in New South Wales. I really think that something needs to be done about this, it's just absurd.
  4. Craig Payne

    Craig Payne Moderator

  5. Burke

    Burke Member

    Its the same in Perth. We seem to lack advocacy at the right level in state and federal goverments. Opticians can refer to opthamologists (and they get Medicare rebates!), but podiatrists cant refer to foot ulcer clinics in tertiary hospitals, which podiatrists run.
  6. podesh

    podesh Active Member

    Hi Nigel, last time I spoke to the team, it was to do with funding. Don't forget you can refer to the aged care team in taree, they predominately treat ulcers. I do agree with you, very embarrassing having to go to gp. I had one recently, patient had acute Charcot, gp refused to refer, didn't believe me and he knows I used to work in the high risk team! Luckily, the patient believed me and saw another gp, who followed through.
  7. surfboy

    surfboy Active Member

    That's exactly correct, community Podiatrists across Australia are unable to refer to Podiatrist-run high risk foot clinics at tertiary hospitals. I am amazed and concerned that this is the case. I am also concerned that we in the profession have done nothing about this - we must advocate to change this dangerous clinical practice immediately. But how?! Where is the Podiatry lobby??
  8. APodC

    APodC Active Member

    The APodC has been in Canberra four times this year already, advocating on behalf of podiatrists for improvements to the CDM plans and referrals, access to PBS and MBS, and acknowledgment of the importance of podiatrists in primary care settings. We are guided by our members on which issues to focus at any given time, as their fees help to fund this advocacy and it would be impossible without them. For those on this thread who are members, I hope you completed the recent ‘policy priorities’ survey that was distributed through states to help us identify where you want us directing our attention as an advocacy and lobbying body.

    On the issue of HRF clinics not accepting referrals, this isn't a consistent problem (or a funding problem as far as I know). I'm aware of hospitals that have a referral form into the HRF clinic for pods in their catchment.

    If it's affecting any APodA members, drop us a line and we'd be happy to take it up for you.
  9. Deka08

    Deka08 Active Member

    In our HRFC we have endo's attached to the clinic, (others probably have vascular as well, lucky buggers) and its due to this reason that they prefer the GP referral. This facilitates medication, MRI, and other specialist referrals -> funding source. We have an ulcer clinic operating side by side with our HRFC, and we are a bit relaxed about the rules, ie as long as the referral gets there. So we can kind of back door people through the ulcer/priority 1 clinic, but at the end of the day, the referral is required eventually. It is also nice to keep the GP in the loop as some don't like it when they get a letter from an endo that they haven't referred to. Others are happy that stuff gets done for their patients.
  10. Ros Kidd

    Ros Kidd Active Member

    I'm sure that if you contacted the Local Director of Podiatry they would give you the answer your looking for.
  11. Judy Gates

    Judy Gates Member

    What a pity we can't make a referral similar to a specialist to specialist referral - that lasts is it one or three months? After that period the patient has to get a gp referral.
  12. Chloe P

    Chloe P Member

    I haven't encountered this issue in OLD. I've referred a few times to the high risk clinic at my local public hospital on the Sunshine Coast.
  13. fetefestive

    fetefestive Member

    I'm not certain of the policies or NSW clinics. Albeit the pressures tertiary podiatry centres are under, they receive/reject referrals routinely due to inadequate referral information, & absence of expected baseline diagnostic information that community/private podiatry do/should have the resources to collect.

    In WA it is encouraged that referrals be escalated to tertiary podiatry when it is appropriate. The Scheepers & Howse (2013) framework is unique & is an intervention targeted at the many ulcers in the community that have not been dealt with in a timely fashion. These facilities are very full & are under a lot of pressure to discharge primary care issues to primary care podiatrists as soon as practicable. Nonetheless, see this link for education on the foot ulcer-related education to appropriate timing of referrals: www.scgh.health.wa.gov.au/OurServices/eLearning/5FootSteps/player.html

    Use that framework idea for any atypical situations would be my advice, & in its absence talk to the triage team for any additional advice.

    Troubleshooting for rejected referrals (illuminate clinical reasoning for an escalation in care to a tertiary podiatry setting):
    -Critical consultation with vascular specialist in a multidisciplinary meeting will be accelerated for a critical limb ischaemia (attach vascular laboratory results conducted in your clinic or indicate where they are available from)
    -Critical consultation with orthopaedic specialist in multidisciplinary meeting will be accelerated for a probe to bone or sequela removal situation (indicate bone removal, positive probe to bone testing with metal probe, etc.)
    -Or any other complex pathology or combination of pathologies requiring advanced specialist input into management, multidisciplinary teams, or offloading requirements beyond the resources of a private or community podiatry setting

    There will occasionally be an issue which will appear atypical & requires immediate referral to a vascular specialist. e.g. critical limb ischaemia identified from routine screening & claudication symptom severity, you need a vascular consult immediately before an ischaemic digit, etc. precipitates. Step 1: call the triage nurse at your local tertiary vascular department to see if the patient's current Surgeon or Registrar is available (skip to step 2 if N/A). Step 2: ask triage nurse what options are available, given the urgency of the issue, to get a Surgeon or Registrar to view the patient in the next 24hrs. They will usually indicate if you can get the GP on side that they can get them in for a clinical appointment that day or the next. They will also indicate if it sounds like its a situation best dealt with by sending the patient to their hospital's emergency department, with a letter explaining pathology from the podiatrist that directed the issue CC. the triage nurse at the hospital on the letter, & then their Surgeon or Registrar can deal with the issue in a more timely fashion (usually a last resort if clinical appointment is not possible).

    Caveat: there's probably a lot of high risk diabetic feet that are going to have to be dealt with by supplementing Medicare Chronic Disease care plans out there, or just get worse & turn into a terrible mess "active" foot ulcer at the moment. These centres just don't have capacity to care for all high risk patients, only those with active problems, like Charcot or ulcers, or both. It sucks I know & it's a very expensive thing to precipitate an ulcer when you know the patient has a problem that necessitates 6 weekly reviews, & they won't pay for it if you give them care that frequently. Private health funds, even if you do have good cover, won't pay for basic dressings, offloading, etc. Usually the tertiary podiatrists will try to do what they can but just try to keep it simple & tell them if you just need some simple offloading put in place, then they can discharge back to you.

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