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Zena Bonney, Modbury Hospital - TCP Pathways for aboriginal and Torres strait Islander People: TCP northern adelaide Health
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Zena Bonney, Modbury Hospital - TCP Pathways for aboriginal and Torres strait Islander People: TCP northern adelaide Health


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Zena Bonney, Aboriginal Cultural Advisor, Northern …

Zena Bonney, Aboriginal Cultural Advisor, Northern
Region Older Peoples Health Services, Transitional
Care Program, Modbury Hospital delivered the presentation at the Transition Care: Improving Outcomes for Older People Conference 2013.

The Transition Care: Improving Outcomes for Older People Conference explores a combination of residential and community transition care programs. It also features industry professionals' experiences in transitional aged care, including the challenges and successes of their work.

For more information about the event, please visit:

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  • 1. Pathways for Aboriginal and Torres Strait Islander People TCP Northern Adelaide Local Health Network Date:2013
  • 2. We acknowledge that the land we meet on today is the land of the Gadigal people of the Eora Nation. We pay our respect to Elders past and present, to their Ancestors and to other Aboriginal and Torres Strait Islander people present today.
  • 3. Overview  My story  TCP Project  Meeting the needs of older Aboriginal People  Cultural awareness, choices and flexibility  Case studies  Evaluation
  • 4. Background of the Aboriginal Transition Care Project SA Health recognised the need to increase the uptake of TCP within the Aboriginal community SA Health employed Project Workers to cover the South, Central, Northern and Country Regions Project Workers Identified and developed state- wide TCP Pathways Explored and developed strategies to address key issues The Aboriginal Project Officers bring a strong understanding of the cultural diversities that exist within both Country and Metropolitan Aboriginal communities.
  • 5. Aboriginal Transition Care Project Our Vision The Transition Care Program recognises the complexity and the unique ageing process of Aboriginal people. The impact of co-morbidities in the recovery process and the importance of their roles in societal wellbeing of the Aboriginal community. We acknowledge the life experiences of older Aboriginal and Torres Strait Islander peoples.
  • 6. Meeting the needs of older Aboriginal people There is an ongoing challenge to ensure health services are responsive to the needs of Aboriginal and Torres Straight Islander people Many Aboriginal and Torres Strait Islander people have a lifespan that is up to 17 years shorter than other Australians. Whereas older people in the general population are considered for TCP when over 65 years. It is sometimes appropriate to plan and deliver services of this type to Aboriginal people as young as 50 years to ensure that they receive equitable services consistent with their needs.
  • 7. How the TCP Program has supported the role as Cultural Advisor  New Model -2013  The role of Aboriginal and Torres Strait Islander Cultural Advisor has been expanded to work with all older people services in NALHN, recognising that clients may require something other than TCP. The role now accommodates this broader approach.  The service operates with a client centred perspective, the clients needs are paramount.
  • 8. The new Model - 2013  All services now have the ability to seek consultation with the ATSI Cultural Advisor and direct client assistance will be available when required. The ATSI Cultural Advisor will also provide direct referrals to each service if appropriate.  In order to facilitate this new collaboration the ATSI Cultural Advisor will seek consultation with key personnel within each team to discuss the activity parameters and protocols for best practice
  • 9. Sharing of information and knowledge with nursing,allied health personnel, the wider hospital system, Aboriginal and main stream services
  • 10. ATSI TCP Cultural Advisor Pathway ATSI person admitted to Hospital ATSI TCP Cultural Advisor notified via email ATSI TCP Cultural Advisor visits client & Assesses care needs Suitable for TCP Not suitable for TCP TCP referral completed Continued ATSI TCP Cultural Advisor support Referred to support services Planned discharge including referral to support services ATSI TCP Cultural Advisor contacted about potential hospitalisation Evaluation
  • 11. Northern Adelaide Local Health Networks “YARN – UPS” Informal information sharing about the Transition Care Program to: Elders, Aboriginal Health Service Aged Care Providers, Community Forums ‘Nunga Grapevine
  • 12. TCP- Contributing to CTG – Close The Gap – Aboriginal health equality TCP encourages the interrelationships and values the networking between services. Aboriginal and mainstream services working collaboratively together for the best outcome of the client TCP recognizes the gap in life expectancy, hence the age for ATSI TCP is 50yrs, where as mainstream is 65 yrs.
  • 13. Challenges  Identification  Lack of culturally appropriate resources  Lack of knowledge  Relationships/Communication  Networking
  • 14. Case Study 1- TCP Northern Adelaide Local Health Network 57 year old Aboriginal man 3 hospital admissions in 4 months Complex chronic disease and co-morbidities Reluctant to accept services Multiple hospital visits prior to TCP uptake
  • 15. Case study -1  TCP information was left for the client to read and or share with family  The client gained trust, felt worthy and did end up accepting a community TCP which led to a CACP in discharge  Finally the clients health also improved extensively, due to accessing the appropriate services
  • 16. Case Study -2 77 year old Aboriginal Lady Admitted to hospital due to a fractured neck of femur Hospital stay consisted of over a month Patient was then transferred to a rehabilitation program with in a different Hospital Patient made very good progress Patient was discharged home onto RITH and then TCP
  • 17. Case Study 2 A comprehensive TCP program was set up and services continued in her home for 10 weeks Regular Case Management/advocacy meeting were attended Regular Family meetings held All networks worked collaboratively Client now lives independently in her home, and has made many new friends during her journey
  • 18. MY role as Cultural Advisor  Monthly reports  Recording  Data collection  Consultation protocols  Referral processes  Cultural advocacy  Meetings and Education sessions  Multi D liaison  Service needs  Accessing Clients
  • 19. Questions?