Walgan Tilly –
                                              Improving Aboriginal
                                        ...
Clinical Services Redesign is part of the strategy
to transform the NSW health system




Process Improvement      Perform...
Redesign follows a robust framework for
improving clinical processes

   Project                     Solution    Implement...
120+ projects have resulted in new ways of
delivering better care for patients & carers
New Models of Care have been publi...
Aboriginal Chronic Care

•   Would Redesign work in Aboriginal Health?
•   What needed to be different?
•   What are we ac...
Chronic Disease in NSW

                               Percentage Long Term Conditions
                               (ABS...
Closing the Gap

Aboriginal life expectancy rates are still considerably
lower than non-Indigenous Australians.
Younger Population
The Aboriginal population is generally younger than
the non-Aboriginal population.




                ...
Dying Younger
Aboriginal and Torres Strait population is dying younger
than the non-Indigenous population.




           ...
The experts said:

• Poor identification of Aboriginal patients in Area Health
  Services
• Screening for Chronic disease ...
Patients and Carers said:

• No regular GP
• Limited after hours support services
• Lack of Aboriginal health staff across...
Walgan Tilly - Aboriginal Specific Redesign


• Practical steps and real
solutions to improving access
to chronic disease ...
Walgan Tilly – An overview

• Three diagnostic site visits
    •   Over 80 Key Stakeholder Interviews
    •   26 Patient a...
Scope of Practice

• Aboriginal people 15 years & over with or at risk
  of a chronic disease
  –   Heart
  –   Diabetes
 ...
State Wide Solutions

  • Model of Care for Aboriginal People
  • Integration of Aboriginal Health and mainstream
    Chro...
Area Health Solutions

NCAHS            •   Model of care.


GSAHS            •   Aboriginal cultural awareness program to...
Change in Direction
Key Performance Indicators

Indicator                                                                                     ...
Cardiac Rehab Data
Respiratory Rehab Data
Improve Data Quality

• Identification of Aboriginal people

• The standard question to ask is:
  “Are you of Aboriginal o...
Identification Data

                             % of Inpatient Separations without Aboriginal Indicator Recorded
       ...
48 Hour Follow up
    Processes will need to be tailored to each facility                                                 ...
48 Hour Follow up Data




     Data collected by Area Health Services and reported to Chronic Care for Aboriginal People ...
Model of Care
Clinical Indicators

• HbA1c – Diabetes

• Spirometry – Respiratory

• Blood pressure – Heart

• Albumin to Creatinine Rat...
Challenges

• Identification of Aboriginal patients
• Workforce – clinical and non clinical positions, getting
  the mix r...
Working in Aboriginal Health

 • Find out how the community works, community
   protocol and leaders
 • Consider the capac...
Next Steps

 • Work with Commonwealth on National Partnership
   Agreement “Closing the Gap”
 • Finalise implementation of...
Key messages - Chronic Care for Aboriginal
People Program

 • Redesign does work in Aboriginal Health
 • Importance of tru...
Acknowledgements

• Area Health Service Project Leads

• Area Managers Aboriginal Health

• Executive Sponsors

• Particip...
Chronic Care for Aboriginal People Program

 • Raylene Gordon – Program Manager
 • Eunice Simons – Senior Project Officer
...
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Walgan Tilly 2010

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NSW redesign of Indigenous Health programs

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Walgan Tilly 2010

  1. 1. Walgan Tilly – Improving Aboriginal Chronic Care James Dunne A/State-wide Program Director NSW Health Artist: Bronwyn Bancroft Centre for Aboriginal Health
  2. 2. Clinical Services Redesign is part of the strategy to transform the NSW health system Process Improvement Performance Increased capacity Management Changing the way An additional 2700 we do things to Increased beds funded improve processes managerial focus between 2004 - 2008 and deliver better on targets and patient journeys performance
  3. 3. Redesign follows a robust framework for improving clinical processes Project Solution Implementation Implementation Sustainability Diagnostic Monitoring Initiation Development • 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
  4. 4. 120+ projects have resulted in new ways of delivering better care for patients & carers New Models of Care have been published 18 best practice Models of Care have been captured http://www.archi.net.au New Tools have been developed Including 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 designed Including fast track zones, Medical Assessment Units, Patient Flow Units, hospital avoidance initiatives, Hospitalists BUT…rollout & sustainability still an issue
  5. 5. 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?
  6. 6. Chronic Disease in NSW Percentage Long Term Conditions (ABS 2007 NSW Indigenous Health Status) 25 20 15 % 10 5 0 Arthritis Asthma Diabetes/high sugar Heart and High blood High blood pressure Neoplasms levels circulatory cholesterol problems/diseases Indigenous Non-Indigenous
  7. 7. Closing the Gap Aboriginal life expectancy rates are still considerably lower than non-Indigenous Australians.
  8. 8. Younger Population The Aboriginal population is generally younger than the 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
  9. 9. Dying Younger Aboriginal and Torres Strait population is dying younger than the non-Indigenous population. OATISH – Aboriginal and Torres Strait Islander Health Performance Framework – 2008 Report
  10. 10. 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
  11. 11. Patients and Carers said: • 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
  12. 12. 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
  13. 13. Walgan Tilly – An overview • 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
  14. 14. Scope of Practice • Aboriginal people 15 years & over with or at risk of a chronic disease – Heart – Diabetes – Lung – Kidney
  15. 15. 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
  16. 16. 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.
  17. 17. Change in Direction
  18. 18. Key Performance Indicators Indicator Target Commence implementation of Aboriginal Chronic Disease Management Walgan Tilly Area specific as per Walgan Tilly Project solutions PAS identification of Aboriginal people consistent with PD2005_547 Aboriginal and <1% unknown responses + Torres Strait Islander origin – recording of information of patients and clients mandatory training % of Aboriginal people with a chronic disease participating in and completing in a 60 % Rehab, ComPacks or CAPAC program % 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 90% provider team
  19. 19. Cardiac Rehab Data
  20. 20. Respiratory Rehab Data
  21. 21. Improve Data Quality • Identification of Aboriginal people • The standard question to ask is: “Are you of Aboriginal or Torres Strait Islander origin?”
  22. 22. Identification Data % of Inpatient Separations without Aboriginal Indicator Recorded Facility Type 'H' or 'M' Only 1.40% 1.20% 1.00% 0.80% 2007/08 2008/09 0.60% 2009/10 0.40% 0.20% 0.00% Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Demand Performance Evaluation Branch, NSW Department of Health 2007-2010 HIE data- admitted patients
  23. 23. 48 Hour Follow up Processes will need to be tailored to each facility Follow up takes place Remaining in  Discharge  Discharge  Identification Acute Care the  Planning Information community Processes to keep  Information provided to  48 hour follow up  As soon as Chronic  Commences at  patient informed of  patient / family  takes place  Care patient who  admission identifies as Aboriginal  discharge  regarding discharge  proceedings – patient  requirements, plans,  Linking patients to  arrives at facility Family involvement able to decline follow  medications appropriate services  Standard method of  Patient involved and  up Discharge summaries,  Phone call notification, e.g. ward  aware of 48 hour follow  NUM, ALO, DC  up process Patient clinical / social  phone numbers and  networks and future  information forwarded  Home visit planner, pager Linked directly to follow  requirements defined  to person responsible  up process and person  for follow up  responsible Transfer of information and reporting processes
  24. 24. 48 Hour Follow up Data Data collected by Area Health Services and reported to Chronic Care for Aboriginal People Program, NSW Health
  25. 25. Model of Care
  26. 26. Clinical Indicators • HbA1c – Diabetes • Spirometry – Respiratory • Blood pressure – Heart • Albumin to Creatinine Ratio - Kidney
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Key messages - Chronic Care for Aboriginal People Program • Redesign does work in Aboriginal Health • Importance of trust, listening and building relationships • Long term process
  31. 31. Acknowledgements • Area Health Service Project Leads • Area Managers Aboriginal Health • Executive Sponsors • Participating Aboriginal communities • Clinical Services Redesign Teams • Many contributors & advisors
  32. 32. Chronic Care for Aboriginal People Program • Raylene Gordon – Program Manager • Eunice Simons – Senior Project Officer • Rachael Havrlant – Senior Project Officer
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