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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