Artist: Bronwyn Bancroft

Centre for Aboriginal Health

Walgan Tilly –Improving Aboriginal Chronic Care

James DunneA/State-wide Program DirectorNSW Health

Clinical Services Redesign is part of the strategy to transform the NSW health system

Increased capacityPerformance Management

Process Improvement

Increased managerial focus

on targets and performance

An additional 2700 beds funded

between 2004 - 2008

Changing the way we do things to

improve processes and deliver better patient journeys

Redesign follows a robust framework for improving clinical processes

Project Initiation Diagnostic Solution

DevelopmentImplementation Implementation

MonitoringSustainability

• Frontline staff use the methodology• Identify issues across the patient journey• Design solutions• Implement the best solutions

• Ensure we analyse problems before developing solutions by utilising data analysis, project & change management

• Delivers long-term sustainable changes

120+ projects have resulted in new ways of delivering better care for patients & carers

New Models of Care have been published18 best practice Models of Care have been captured http://www.archi.net.au

New Tools have been developedIncluding ambulance arrivals board, Ambulance Clinical Services Matrix, electronic bed board, WAND, risk assessment tools (e.g falls, delirium), and demand management tools

New Approaches have been designedIncluding fast track zones, Medical Assessment Units, Patient Flow Units, hospital avoidance initiatives, Hospitalists

BUT…rollout & sustainability still an issue

Aboriginal Chronic Care

• Would Redesign work in Aboriginal Health?• What needed to be different?• What are we actually dealing with?• How can Redesign contribute to improving the health of

Aboriginal people?

Chronic Disease in NSW

Percentage Long Term Conditions (ABS 2007 NSW Indigenous Health Status)

0

5

10

15

20

25

Arthritis Asthma Diabetes/high sugarlevels

Heart andcirculatory

problems/diseases

High bloodcholesterol

High blood pressure Neoplasms

%

Indigenous Non-Indigenous

Aboriginal life expectancy rates are still considerablylower than non-Indigenous Australians.

Closing the Gap

Younger PopulationThe Aboriginal population is generally younger thanthe non-Aboriginal population.

NSW Dept Health (2006) – E‐CHO Report of the NSW Chief Health Officer

NSW Dept Health (2006) – E-CHO Report of the NSW Chief Health Officer

Dying YoungerAboriginal and Torres Strait population is dying youngerthan the non-Indigenous population.

OATISH – Aboriginal and Torres Strait Islander Health Performance Framework – 2008 Report

The experts said:

• Poor identification of Aboriginal patients in Area Health Services

• Screening for Chronic disease in Aboriginal patients not happening

• Insufficient resources to conduct care in the home and in the community

• Poor communication between primary and secondary providers

• No regular GP

• Limited after hours support services

• Lack of Aboriginal health staff across all services

• Affordability of medical services, specialist services and medications

• Cost of travel and accommodation for care

• Transport

• No follow up on discharge, no treatment plans

Patients and Carers said:

Walgan Tilly - Aboriginal Specific Redesign

• Practical steps and real solutions to improving access to chronic disease services.

• Building working relationships between Aboriginal and mainstream chronic disease services

• Identification and sharing of best practice in meeting the needs of Aboriginal people with chronic disease

• Three diagnostic site visits• Over 80 Key Stakeholder Interviews• 26 Patient and Carer Interviews• 68 people involved in patient journey process mapping

• 14 Validation workshops (involving approximately 250 people)

• 13 Area and Justice Health solution workshops (involving approximately 350 people)

• Literature scan – ‘Food for thought’ document

• Data analysis of available health data – HIE, Medicare, ABS

• Now at Implementation, complete in June 2010

Walgan Tilly – An overview

Scope of Practice

• Aboriginal people 15 years & over with or at risk of a chronic disease– Heart– Diabetes– Lung– Kidney

State Wide Solutions

• Model of Care for Aboriginal People

• Integration of Aboriginal Health and mainstream Chronic Care

• Greater Aboriginal cultural awareness and cultural sensitivity of services

• Justice Health linkages

• Improved access to primary care

• Improved data quality

Area Health Solutions

NCAHS • Model of care.

GSAHS • Aboriginal cultural awareness program to be included in essential (mandatory) training for GSAHS staff, and offered to other service partners.

• Shared private/public holistic model of care for Aboriginal people with or at risk chronic disease.

GWAHS • Implementation of the Women’s Elders program.• Reintroduction of the Well Person’s Health Check.• Introduction of the S100 medication program.• IPTASS education for Medical Offices.• Enhanced use of the AHW in the client/doctor interaction.• Introduction of care plans by multi-disciplinary teams.• Standardise the hand-over procedure between services.

HNEAHS • Improve the access to mainstream renal and chronic disease services for the Aboriginal community.

NSCCAHS • Further consultation (including with Aboriginal community) in solution design.• Identify Aboriginal patients/clients with documented process and follow-up.• Closer local analysis of causes of cost issues.

SSWAHS • Culturally sensitive and effective discharge including 24 hour follow-up service.• Provision of Care/Prevention.

SWAHS • Models of Care-Identify and Modify.• 24-48 Hour follow-up service.• Model of Care-Health Checks.

SESIAHS • Link into existing mainstream transport systems in partnership with the “Transport for Health” project for equitable access to services.

• Compile a resource directory of mainstream health services to distribute to the Aboriginal community.• Provide and promote evidence based chronic care education to the Aboriginal community.

Justice Health • To ensure that Aboriginal people in custody in NSW Correctional Centres and Juvenile Justice Centres with and at risk of chronic conditions access and utilise existing chronic disease and care services.

Change in Direction

Indicator Target

Commence implementation of Aboriginal Chronic Disease Management Walgan Tilly Project solutions Area specific as per Walgan Tilly

PAS identification of Aboriginal people consistent with PD2005_547 Aboriginal and Torres Strait Islander origin – recording of information of patients and clients

<1% unknown responses + mandatory training

% of Aboriginal people with a chronic disease participating in and completing in a Rehab, ComPacks or CAPAC program 60 %

% of Aboriginal patients with chronic disease followed up within 48 hours or 2 working days of a discharge from hospital, by any member of the agreed health provider team

90%

Key Performance Indicators

Cardiac Rehab Data

Respiratory Rehab Data

Improve Data Quality

• Identification of Aboriginal people

• The standard question to ask is:“Are you of Aboriginal or Torres Strait Islander origin?”

% of Inpatient Separations without Aboriginal Indicator RecordedFacility Type 'H' or 'M' Only

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2007/08

2008/09

2009/10

Identification Data

Demand Performance Evaluation Branch, NSW Department of Health 2007-2010 HIE data- admitted patients

Identification

As soon as Chronic Care patient who identifies as Aboriginal arrives at facility

Standard method of notification, e.g. ward NUM, ALO, DC planner, pager

Acute Care

Processes to keep patient informed of discharge proceedings – patient able to decline follow up

Patient clinical / social networks and future requirements defined 

Discharge Planning

Commences at admission

Family involvement

Patient involved and aware of 48 hour follow up process

Linked directly to follow up process and person responsible

Discharge Information

Information provided to patient / family regarding discharge requirements, plans, medications

Discharge summaries, phone numbers and information forwarded to person responsible for follow up 

Remaining in the community

48 hour follow up takes place 

Linking patients to appropriate services 

Phone call

Home visit

Processes will need to be tailored to each facility

Transfer of information and reporting processes

Follow up takes place

48 Hour Follow up

48 Hour Follow up Data

Data collected by Area Health Services and reported to Chronic Care for Aboriginal People Program, NSW Health

Model of Care

Clinical Indicators

• HbA1c – Diabetes

• Spirometry – Respiratory

• Blood pressure – Heart

• Albumin to Creatinine Ratio - Kidney

Challenges

• Identification of Aboriginal patients• Workforce – clinical and non clinical positions, getting

the mix right• Data/IT - Sharing of information across services &

settings• Executive Sponsorship• Partnerships between Aboriginal Health and other

services• Developing trust with Aboriginal patients

Working in Aboriginal Health

• Find out how the community works, community protocol and leaders

• Consider the capacity of other providers to contribute to project

• Respect what people do well

• Develop local protocols with local stakeholders

• Listen to what is NOT being said

• Respect Cultural & Family obligation of Aboriginal staff

• Acknowledge local expertise

• Don’t promise what you can’t deliver

Next Steps

• Work with Commonwealth on National Partnership Agreement “Closing the Gap”

• Finalise implementation of State and Local solutions

• Work with Area Health Services on sustainability of project solutions

• Integrate solutions into mainstream chronic care strategies

• Align project with any future initiatives around chronic disease

• Evaluate the project

Key messages - Chronic Care for Aboriginal People Program

• Redesign does work in Aboriginal Health

• Importance of trust, listening and building relationships

• Long term process

Acknowledgements

• Area Health Service Project Leads

• Area Managers Aboriginal Health

• Executive Sponsors

• Participating Aboriginal communities

• Clinical Services Redesign Teams

• Many contributors & advisors

Chronic Care for Aboriginal People Program

• Raylene Gordon – Program Manager

• Eunice Simons – Senior Project Officer

• Rachael Havrlant – Senior Project Officer