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Gout team roles (clinical and non-clinical).docx
Here is a list of the roles that you may need within your team. Some roles may be combined
| Role | Description | Person |
|---|---|---|
| Project sponsor | Responsible for the overall success of the project, provides resources, and helps to remove barriers to success. | |
| Day-to-day leadership of the project | Ensures project meets milestones, contact point for questions | |
| Clinical leadership | Answers clinical questions outside of agreed clinical knowledge | |
| Data collection | Initial data collection, refining of data collection to reflect the scope of the project and resources, providing regular data reports to all members of the team to monitor and track progress | |
| Prescriber and referrers | Uric acid lowering medicine, prophylaxis, and acute gout attack medicines. Refer to the local pharmacy for medicine initiation and titration; rheumatology services for complex clinical issues | |
| Initiation and titration of uric acid lowering medicine | Provide information about the initial dosage, when to take, the medicine, need to come back within a month for POC testing and titration/dose increase, and who to report side effects to, especially serious side effects. Advise person when reaching treatment goal and to attend for POC in 6/12 months. | |
| Barriers to access | Ongoing role to identify any new barriers to implementation of project outcomes and leading discussions about possible solutions within wider team. | |
| Collective leadership | Everyone supports the project aim of achieving equitable outcomes for whānau Māori and Pacific peoples with gout and works to achieve that aim by participating in project activities. |
The roles below could be managed by non-clinical team members, eg, health coach, kaiawhina or community support worker.
| Role | Description | Person |
|---|---|---|
| Patient contact, engagement and supporting decision making | Contact whānau Māori and Pacific peoples with gout. | |
| Find out person’s understanding about gout, provide new information about causes of gout, gout medicines, and need to take every day. | ||
| Support person with gout to work through decision to take daily medicine. | ||
| POC (Point of Care) testing | In practice at initial appointment, at initiation of uric acid medicine, titration and at agreed intervals to check treatment goal maintained. Could also be provided in the community and at home visits. Read more about POC testing. | |
| Ongoing contact and follow up/ case management | Follow up of whānau Māori and Pacific peoples with gout for the first 12 months during initiation and titration, ensuring continuity of supply, and taking uric acid lowering medicines every day, providing a link to prescribers and/or other healthcare team members to resolve any issues. | |
| Follow up once treatment goals achieved, ensuring continuity of supply and blood test every 6/12 months as agreed with clinician) and proactively addressing any identified barriers. | ||
| Bridge between person with gout and practice | With people who have not yet decided to take uric acid medicines to check impact of gout and if they have changed their minds, ensuring people have a point of contact within practice. | |
| Assisting with access, navigation, reducing complexity, answering questions. | ||
| Addressing mental wellbeing challenges | Whānau Māori and Pacific peoples’ concerns such as anxiety about taking daily medicines, stigma and self-blame about gout, change of identity once starting on daily medicines |
Download entire roles list:
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If health improvement practitioners (HIPs) health coaches, kaiawhina and/or community support workers are part of your team, they could undertake some of these roles. For example, HIPs could assist with mental wellbeing challenges and health coaches, kaiawhina and community support workers could be involved in patient contact, point of care (POC) testing, ongoing contact, case management and follow-up and more.
A lot of the ongoing conversations between your team and your whānau Māori and Pacific peoples with gout don’t require a health professional until the conversation is about the prescribing of medicines.
From the ProCare Gout Collaborative: A health coach can help identify a person’s knowledge and beliefs about gout and unpack those to help the person think about the value and role of long-term medicines. They can also share stories of family members having to start taking allopurinol because of kidney issues from frequent gout attacks
From the ProCare Gout Collaborative: One practice used its health coach (under the clinical leadership of the Nurse Leader) to contact all whānau Māori and Pacific peoples with gout. They were offered a free consultation with the health coach to talk about their understanding of gout, impact, causes and need to consider long term uric acid medicine. Once someone decided to start uric acid medicine they were referred to their usual GP.
From the ProCare Gout Collaborative: Another practice used 2 nurses to contact all male Māori and Pacific peoples with gout within a specified age range. Nurses offered a free consultation to talk about the person’s understanding of gout, impact, causes and need to consider long term uric acid medicine. Once a person decided to start uric acid medicine they were referred to a GP.
From the ProCare Gout Collaborative: Another practice used a HIP and 2 health coaches (under the clinical leadership of the nurse leader) to contact all whānau Māori and Pacific peoples with gout and offer them a free appointment either at the clinic or at home. Consultations (single or multiple) with the health coaches covered understanding of gout, impact, causes and need to consider long term uric acid medicine. Once someone decided to start uric acid medicine they were referred to a GP.
From the Whanganui GOUT STOP programme evaluation report: Getting the implementation right is the key to programme reach and success. Give careful consideration to the skills, competencies and roles included when establishing the leadership and implementation team.
Ensure that your team is able and supported to deliver the activities in the plan, and that required resources are secured.
When delivering your project use any tools and resources available to encourage your team’s activity. This includes establishment of champions, directing Cornerstone activities towards the topic of gout, including health improvement practitioners (HIPs) and health coaches in routine pathways, and provision of regular feedback on progress.