Allied HealthWays – a clinical guidance website for allied health in an integrated health system

Keywords: allied health professionals, clinical pathways, community, consensus, health system change, patient care, quality improvement, survey, trust, whole of system.

This paper describes the development, implementation, and monitoring of Allied Healthways, a HealthPathways website for allied health that was set up in 2017.

From 2008, the Canterbury health system adopted a whole-system approach focused on providing more health care in the community, making the best use of specialised and scarce resources, and ‘doing the right thing’ for the patient.¹

There was a need to optimise the use of allied health resources, across private and public settings. For a system working towards integration, there was limited communication and a lack of awareness and trust among allied health professions, and among allied health and other community professions, including general practice. A recent report for Allied Health Aotearoa New Zealand supports this, and states that referrals from general practice to allied health are minimal, with a reluctance to trust patient care to allied health.²

Integration and devolution of services to allied health in community settings was difficult, and the ‘way we do things’ was not agreed upon or documented in a commonly available platform for allied health professionals. For example, there was no agreed package of conservative care for patients before requesting orthopaedic surgical services.³

There was no common means for consensus and communication about clinical care among allied health professions. Allied health managed their clinical guidance in profession-based silos and specific settings (eg Physio 24-7), which was an online resource specifically for physiotherapists working in the acute setting at Christchurch Hospital.

HealthPathways had been developed by the Canterbury Initiative (a change management group funded by the Canterbury District Health Board, now Te Whatu Ora Waitaha), and Streamliners New Zealand Limited.⁴ Online clinical pathways, developed on the basis of local agreement among clinicians and informed by evidence, became the ‘way we do things’ in the Canterbury health system.⁵ Guidance on common health conditions, combined with local process and directory information, was communicated and well utilised on sites for general practice and for junior doctors.^6,7 Patient information was closely linked into the platform, with HealthInfo Canterbury providing trusted, reliable information on health conditions, support services, and wellbeing for the general public. The success of Community HealthPathways resulted in widespread use in New Zealand and Australia, and there is now increasing use in the United Kingdom.⁸ However, there was no platform to develop and share clinical guidance for Canterbury allied health professionals in the way there was for other professional groups.

The objective of this initiative was to develop an online clinical guidance tool for all allied health. It was decided to build on the existing HealthPathways platform, using the standard approach:

1. Engagement with clinicians to provide clinical governance, subject matter expertise, and negotiate pathways that reflect local best practice

2. Pathway clinical editors to liaise with the subject matter experts and develop pathway content

3. Plain English technical writers and a standard pathway format that makes information easy to navigate and read

4. Education sessions (in-person and webinar) and multiple forms of communication.

Anticipated benefits of the new website, to be called Allied Healthways, included:

1. Providing a communication tool across the health system for allied health

2. Regularly used clinical pathways that allow everyone to provide a consistent level of care, irrespective of setting or profession

3. Use of the website for the development and implementation of improvement projects

4. Better understanding and trust across the health sector, including among allied health professions, and within each profession across community and hospital care

5. Use as a tool to improve equity

6. Provision of consistent, approved patient information by allied health.

It is difficult to measure the impact of a tool used broadly across a range of services and as part of a suite of related activities. Publications on HealthPathways have discussed these difficulties and summarised existing research.⁹ There was no structured framework used to evaluate Allied Healthways; however, progress has been monitored in a variety of ways, including focus groups, a survey, reviewing data on Google Analytics and collecting evaluation feedback from education sessions.

In 2018, focus groups were established, which included 70 allied health professionals working for the Canterbury District Health Board. Many clinicians were not aware of Allied Healthways. Barriers to use included a lack of release time to help develop or review pathways, limited management support and communication about the value of HealthPathways, IT access issues and having only limited relevant content on Allied Healthways due to the early stage of development. Education sessions about Allied Healthways were subsequently held.

The content on Allied Healthways continues to grow, with over 100 pathways and 40 request pages, with local process directory and referral information, agreed upon and published. Data on pathway usage, captured via Google Analytics, shows there are now more than 13 000 users across the Canterbury health system. As shown in Fig. 1, usage has consistently trended upward over time. A snapshot of the 20 most-viewed pathways on Allied Healthways in the year 1 September 2021 to 31 August 2022 is shown in Table 1.

Fig. 1.  Use of Allied Healthways between 1 September 2017 and 30 June 2022.

Table 1.  Most frequently viewed topics on Allied Healthways, 1 September 2021–31 August 2022 (from Google Analytics, Allied Healthways data analysis system).

Many health professionals have been engaged in the development of Allied Healthways, with >600 direct engagements with subject matter experts, either individually or as part of workgroups. The subject matter experts were local experts, or typical allied health professionals caring for relevant patients, and represented a mix of different allied health disciplines across the health system. They were recommended by their senior managers, colleagues or they expressed interest (eg following invitations sent out from local branches of professional bodies). They needed to commit some time to a workgroup or review of the pathway, and to communicate progress with colleagues, but expectations of involvement were kept limited. There have been >20 workgroups, usually with six to eight health professionals, although some topics, such as palliative care, had up to 20 involved. At least 10 professions have been involved in pathway development and review, including chiropractic, dietetics, occupational therapy, optometry, osteopathy, physiotherapy, podiatry, psychology, speech and language therapy, and social work.

A survey of allied health professionals in Canterbury was carried out in 2021. The methodology and findings of this survey are presented in Supplementary File S1. Respondents valued the site, and the majority (89%) of those using Allied Healthways were in favour of it becoming a nationally available tool. The ability to keep local variation in services visible was the main concern raised with a national model. The Canterbury Initiative has out-of-scope ethical approval to carry out surveys as part of routine service review and improvement.

An average of four education sessions for allied health were delivered per year, aiming to raise awareness of recently developed pathways or wider health system goals. There have been 11 in-person education sessions, with a total of 1157 attendees, and eight webinars with a total of 926 attendees. The sessions were rated highly, with attendees identifying they would use the information to improve or develop their professional practice, along with generally positive comments such as, ‘These webinars are always so well presented, relevant and pitched at the right level’.

An important strategy in developing pathways was to have local clinical conversations with allied health professionals. In our experience, workgroups were an effective way of engaging clinicians, and collaborative relationships were built while developing locally agreed pathways. For example, chiropractors, osteopaths, and physiotherapists involved in the low back pain workgroup commented, ‘It was professionally invigorating’, ‘I find it inspiring that we as dogs, cats and mice have worked so constructively together’, and ‘This must be the first time in the history of our professions in NZ that something like this has been achieved.’

The process of developing pathways enabled improvements to be designed and then implemented.

For example, a workgroup of dietitians developed consistent processes and patient information for patients being discharged from the hospital on home enteral nutrition and documented the agreed changes on Allied Healthways.

Another workgroup developed group education for patients with irritable bowel syndrome (IBS) to learn about a diet low in fermentable carbohydrates (the low FODMAP diet). This was set up in the community in response to unmet need, and access criteria were documented on the IBS pathway. Another example involved hand therapists and surgeons negotiating a package of conservative management for conditions such as trigger finger, which was outlined on pathways as a step required before assessment for surgery.

The pathways document ‘how we do it round here’ and each website page has a feedback button so clinicians can communicate any gaps, disagreements or updates required.

Alongside the formal education programme, the Allied Healthways website is used for professional development. The survey and anecdotal feedback indicated that Allied Healthways is used as a tool to support orientation and training (eg for new graduates), clinicians who are new to an area, and those working rurally, which has the potential to help address geographical equity across Canterbury.

Allied Healthways aims to raise awareness of best practice for Māori health equity, which we have done with expert guidance from the department of Māori/Indigenous Health Innovation, University of Otago. Steps taken include communicating prevalence rates of health conditions for Māori compared with non- Māori on relevant pathways, as well as any evidence that Māori are not receiving best practice. Available hauora Māori providers in Canterbury are outlined on a request page, aiming to mitigate barriers to care. Culturally relevant advice has been integrated into the pathways using te reo Māori to refer to key concepts. For example, in the Cognitive Impairment pathway, there is a paragraph that states, ‘If the patient is Māori, be aware that in Te Ao Māori, mate wareware (dementia) may not be considered to be an illness or a disease, but rather as part of a spiritual journey and as a normal consequence of growing old and preparation for joining tūpuna’. Education sessions with a focus on practical tips to address equity have also been held for allied health.

Allied Healthways has filled a gap in the provision of clinical guidance for allied health professionals, as highlighted by a comment from the survey, ‘To my knowledge there is currently no other national platform available that provides allied health professions with the clinical guidance and the comprehensive range of patient information that Allied Healthways does. There may be sites that individual disciplines use but not a site that caters for all allied health disciplines and encourages a collaborative and multidisciplinary approach to patient care’.

The HealthPathways platform now includes a view of pathways for four key audiences: patients, general practice teams, junior doctors at the hospital, and allied health professionals. The HealthPathways team is sometimes asked why there is not one pathway for all audiences. Although the patient journey should be consistent, irrespective of their point of contact with the health system, guidance and processes need to be relevant to the key target audience. The content on Allied Healthways is aligned with the other HealthPathways sites, but is tailored to reflect the differences in care provided by allied health professionals (eg to include detail on allied health conservative management, modifiable lifestyle measures, and preventative care while excluding detail on prescribing medication). Clear stop-go points for different disciplines to work within their scope are outlined, and the request pages enable appropriate referral within and between disciplines and other services and agencies. The family violence pathway is a good example of how different steps are outlined depending on the clinician’s scope of practice and expertise, as well as the setting they work in (hospital or community). This approach builds trust and supports interdisciplinary working and consistency. Having a targeted site for allied health improves its relevance and optimises the usability and navigation of content.

A pathway’s real value comes from local clinical conversations, focused on process improvements and agreements made during pathway development. Gaining consensus for pathways across diverse allied health professions required a tolerant and collaborative approach, with the ability to compromise when required. Putting the patient at the centre of the discussions helped to provide resolution, due to the common goal of wanting the best for the patient.

Use of Allied Healthways has steadily increased over the 5 years since its establishment, although it does not yet contain relevant content for the wide variety of allied health professions. Although the initial pathways focused on allied health professionals working privately in the community, the scope broadened to include those working for the Canterbury District Health Board in hospital and community settings. Building a critical mass of relevant pathways, both multi-disciplinary and for specific disciplines, and across both community and hospital settings, will be important to encourage users to continue visiting Allied Healthways.

Compared to Community HealthPathways, which is predominantly used at the point-of-care, the Allied Healthways survey identified that only 13% of allied health professionals were using it at the point of care, with the majority using the website before or after a patient consultation. This possibly reinforces the use of Allied Healthways as an education tool for clinicians, although further assessment would be needed to understand this.

Allied health professionals have been empowered to work at the top of their scope. For example, the glaucoma pathway clearly outlines community management by optometrists and when patients should be referred to ophthalmologists, thereby promoting trust and confidence between the professions. Feedback from an occupational therapist on the chronic pain pathway confirms the importance of clinical guidance by stating, ‘It gives me so much more confidence to know that as a generalist OT I am following local guidelines agreed on by colleagues working in the specialist area of pain. I wish I had the pathway sooner!’

Allied Healthways seems to be a useful addition to the HealthPathways platform, and the anticipated benefits have largely been achieved, at least as proof -of-concept. The development of the pathways provides a mechanism for increasing understanding, trust and integration across the health sector. Having Allied Healthways available nationally would enable allied health professionals across New Zealand to provide consistent care and patient information for a wide range of health conditions, localised to their region. This could potentially reduce inequities.

Allied Healthways was funded and developed by the Canterbury District Health Board, which has now been replaced by two central government agencies, Te Whatu Ora/Health New Zealand and Te Aka Whai Ora/Māori Health Authority, who desire national consistency. This change in the structure of the health system provides an ideal opportunity to deliver Allied Healthways as part of a national HealthPathways programme.

Supplementary material is available online.

The data are available from the authors upon request.

The first author is employed by Te Whatu Ora – Health New Zealand, Waitaha – Canterbury (previously Canterbury District Health Board) as the Service Development Manager for Allied Healthways. The second author was previously contracted (until the end of 2021) as a clinical leader for The Canterbury Initiative, by the Canterbury District Health Board. The Canterbury Initiative provided the overarching governance of the Canterbury HealthPathways programme, including Allied Healthways.

This quality improvement paper was developed as part of employment with Te Whatu Ora – Health New Zealand, Waitaha – Canterbury (previously Canterbury District Health Board). There was no specific funding or sponsorship of the paper.