Walgan Tilly –
A/State-wide Program Director
Artist: Bronwyn Bancroft
Centre for Aboriginal Health
Clinical Services Redesign is part of the strategy
to transform the NSW health system
Process Improvement Performance
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
Redesign follows a robust framework for
improving clinical processes
Project Solution Implementation Implementation Sustainability
• 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 published
18 best practice Models of Care have been
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
New Approaches have been designed
Including fast track zones, Medical Assessment Units,
Patient Flow Units, hospital avoidance initiatives,
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
Chronic Disease in NSW
Percentage Long Term Conditions
(ABS 2007 NSW Indigenous Health Status)
Arthritis Asthma Diabetes/high sugar Heart and High blood High blood pressure Neoplasms
levels circulatory cholesterol
Closing the Gap
Aboriginal life expectancy rates are still considerably
lower than non-Indigenous Australians.
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
Aboriginal and Torres Strait population is dying younger
than 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
• Screening for Chronic disease in Aboriginal patients
• Insufficient resources to conduct care in the home and
in the community
• Poor communication between primary and secondary
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
• Cost of travel and accommodation for care
• No follow up on discharge, no treatment plans
Walgan Tilly - Aboriginal Specific Redesign
• Practical steps and real
solutions to improving access
to chronic disease services.
• Building working
Aboriginal and mainstream
chronic disease services
• Identification and sharing of
best practice in meeting the
needs of Aboriginal people
with chronic disease
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
Scope of Practice
• Aboriginal people 15 years & over with or at risk
of a chronic disease
State Wide Solutions
• Model of Care for Aboriginal People
• Integration of Aboriginal Health and mainstream
• 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
• 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.
Key Performance Indicators
Commence implementation of Aboriginal Chronic Disease Management Walgan Tilly
Area specific as per Walgan Tilly
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
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%
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 Recorded
Facility Type 'H' or 'M' Only
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
48 Hour Follow up
Processes will need to be tailored to each facility Follow up takes place
Identification Acute Care the
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
Linked directly to follow requirements defined to person responsible
up process and person for follow up
Transfer of information and reporting processes
48 Hour Follow up Data
Data collected by Area Health Services and reported to Chronic Care for Aboriginal People Program, NSW Health
• HbA1c – Diabetes
• Spirometry – Respiratory
• Blood pressure – Heart
• Albumin to Creatinine Ratio - Kidney
• Identification of Aboriginal patients
• Workforce – clinical and non clinical positions, getting
the mix right
• Data/IT - Sharing of information across services &
• Executive Sponsorship
• Partnerships between Aboriginal Health and other
• 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
• 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
• 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
• Integrate solutions into mainstream chronic care
• Align project with any future initiatives around chronic
• Evaluate the project
Key messages - Chronic Care for Aboriginal
• Redesign does work in Aboriginal Health
• Importance of trust, listening and building relationships
• Long term process
• 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