Chronic Care Coordination by Indigenous Health Workers – A solution

for better care?

Barbara Schmidt & Frank Hollingsworth

AIM OF PRESENTATION

• Explain the context and project design for the Getting Better at Chronic Care in North Queensland project.

• Describe the issues encountered by IHWs during the first 12 months of project implementation; and

• Share examples of the innovation by IHWs and the impact the project has had on IHWs and patients.

GETTING BETTER AT CHRONIC CARE IN NORTH QUEENSLAND PROJECT

Phase 1• Randomised controlled trial of

intensive case management by IHWs

Phase 2• Review of lessons learned• Implementation plan

Phase 3• Economic analysis• Rollout of model

PHASE 1 – CLUSTER RCT

Participants

• Indigenous adults (18-65 yrs) resident in one of the 12 communities

• Diabetes for > 1year (HbA1c>8.5)

• Plus at least one of:– hypertension– chronic obstructive pulmonary disease– coronary heart disease– chronic renal disease (stages 1-3)

PARTICIPATING COMMUNITIES

• Badu• Bamaga• Injinoo• New Mapoon• Seisia• Umagico

• Kowanyama• Mapoon• Mareeba (Mulungu)• Mossman Gorge• Napranum• Yarrabah

PHASE 1 – CLUSTER RCT

Intervention • Intensive case management by Indigenous Health Workers recruited and

trained specifically for the project

• Indigenous Clinical Support Team will provide ongoing training and support

Comparator• Usual care

PHASE 1 – CLUSTER RCT

Primary Outcome

• Reduction in HbA1c at 18 months

Secondary Outcomes

• avoidable hospitalisations

• mortality

• clinical care processes (checks and referrals)

• intermediate outcomes (waist circumference, BP, ACR, eGFR, lipids

etc)

• quality of life

WHERE ARE WE NOW?

• 213 participants enrolled

• Baseline and Go Live data collected

• IHWs recruited to 6 intervention sites

• Initial 3 week intensive training and orientation completed

• Intervention commenced in March 2012

• 2 additional intensive training blocks delivered

• Document review to inform the process evaluation completed

PHASE 1: CLUSTER RCT

SUMMARY OF GOVERNANCE ARRANGEMENTS AND HEALTH SERVICE PROVIDERS

INTERVENTION COMMUNITIES

Community Governance of Health Service

Key service providers Employer of IHW

Badu Island Torres and NPA HHS

Torres and NPA HHSCairns and Hinterland HHS

Torres and NPA HHS

Injinoo Torres and NPA HHS

Torres and NPA HHSCairns and Hinterland HHS

Torres and NPA HHS

Umagico 

Torres and NPA HHS

Torres and NPA HHSCairns and Hinterland HHS

Torres and NPA HHS

Mapoon 

Cape York HHS Cape York HHSACYHC

ACYHC

Kowanyama 

Cape York HHS Cape York HHSACYHC RFDSTorres and NPA HHSCairns and Hinterland HHS

Cape York HHS via service agreement with ACYHC 

Mossman Gorge 

ACYHC ACYHC ACYHC

METHODOLOGY FOR DATA COLLECTION

Document review

• Weekly reports of IHWs

• Weekly supervision reports written by Clinical support team

• Fortnightly Project team minutes

KEY THEMES

• High level of professional satisfaction with the role of care coordinator

• Positive outcomes as a result of education, support and assistance provided by IHW

• Frustration due to issues related to local service context and professional matters

ISSUES ENCOUNTERED BY IHWS

• transport, • staffing levels, • consistency of support services, • quality of service provision, • access to information systems, • office accommodation and

• professional management issues

WHAT HAS BEEN SATISFYING IN MY ROLE?

• Gradual change in attitudes from the clients through education (of what are the causes of chronic diseases).

• Working at grass root level @ the coal face.• Respect and inclusion from community.• Working with a number of allied health

professionals towards goals.• Making better life choices (education that I

provide).

ISSUES I HAVE ENCOUNTERED

• Transport - lack of vehicle to conduct home visits. 6 staff from Mossman Gorge utilise (1) work vehicle.

• Work-space. (Open space within waiting room, cramped and no privacy).

• Medication compliance by clients through lack of understanding the importance of taking their medication as prescribed.

• Community issues (dogs and alcohol) Easy access to Mossman-township where alcohol and illicit drugs is easily accessible.

ISSUES I HAVE ENCOUNTERED

• Work space. Now have the use of a larger office at the Flying Doctor’s well-being centre, which is great for client privacy.

• Co-ordinated home medicine reviews with local pharmacist so that clients have a better understanding of their medications and insulin, and what benefit comes with compliance in keeping up with their medication and the benefit they will receive in the long term.

• Co-ordinate with all staff and give as much notice when I am completing home visits to use vehicle.

• Spoken to community council member to ensure dogs are restrained when completing home visits.

SOLUTIONS TO OVERCOME ISSUES

• Discussions have taken place with Mossman Gorge community to have no alcohol within the community.

• Being an open community this will be extremely difficult to police as all community members will have to agree with such a decision to be implemented.

• With the gradual changes that I see happening with the clients taking a more responsible attitude towards taking better care of their own health we could be seeing a new beginning that is the start of CTG.

• My future role is for me to maintain encouragement and close support with these clients in Getting Better At Chronic Care (GBACC)

SUMMARY

• IHWs are good at doing care coordination, patient education and support when provided the training and support to undertake these tasks.

• IHWs are reporting positive affirmation from their clients and reporting positive outcomes as a result of their efforts

• IHWs are frustrated when they cant deliver the best care possible or these see when their client is not receiving all the care they should

• Challenge for health service managers, policy makers and planners is to remove these low level professional and operational barriers to enable IHWs reach their full potential.

ANY QUESTIONS?

NHMRC PARTNERSHIP GRANT