Specialist outreach and care coordination in primary care are saving lives in Indigenous communities
A couple of months back, an Aboriginal man with vague chest pains attended the Cunnamulla Primary Health Care Centre out on the vast plains of western Queensland.
When the 50-year-old patient mentioned that his brother had died of a heart attack at 45, it caught the attention of visiting general practitioner Dr Noel Hayman. They were more than 700 kilometres from Brisbane, but Dr Hayman was able to quickly consult with the cardiologist in the room next door, Dr William Wang.
A positive stress test later, the patient was taken to Brisbane’s Princess Alexandra Hospital and, sure enough, was diagnosed with coronary artery disease.
“We could medically intervene and keep an eye on him”, Dr Hayman says. “And the story doesn’t end with him having a heart attack like most young Aboriginal guys do.”
The unusual circumstance that saw a cardiologist onsite that morning, practising alongside a GP in a primary care clinic and comparing notes on an Indigenous patient who had come in to express his concern, is a credit to the move towards increased integration of specialist services within Indigenous primary health care.
In the interests of increasing access and improving care for the Aboriginal and Torres Strait Islander population in urban, regional and remote areas — closing the gap — the increased integration means some specialists are now being “referred in” to Indigenous health centres, rather than patients being “referred out”.
Where it is working well, in both urban and remote settings, those providing the frontline care say that it is reducing hospital admissions and even saving lives.
The business case
Dr Hayman and Dr Wang are part of a multidisciplinary team that has been flying from Brisbane to Cunnamulla each month since November 2010.
The expenses associated with the clinics are covered as part of the federal government’s $805 million Indigenous Chronic Disease Package (ICDP) medical specialist outreach assistance program.
The ICDP is itself part of the COAG Closing the Gap scheme.
After nearly three years, the team, comprising Dr Hayman, Dr Wang, endocrinologist Dr Tony Russell and nurses Nola White and Jill Ward, does as many as 100 or more consultations for the 500-strong Cunnamulla Indigenous community during a one- or two-day clinic.
Among other positive results, the extra care has seen the average HbA1c drop dramatically from a high of 9.75% to a tolerable 7.9%.
The clinic’s high attendance rates are important both for generating good health outcomes across the community as well as to make the business case for the specialists taking part.
All consultations are charged through Medicare, so nobody benefits when a specialist travels a couple of hours and sees as few as three patients a day.
“Sometimes there are big costs and sometimes specialists won’t do it because of the remuneration. It’s very difficult — especially if you go out to Woop Woop and no patients turn up”, Dr Hayman says.
But he says that it can take time and care to establish the necessary relationship with the community.
“Wherever you want to go and work in remote communities, you’ve really got to have that strong relationship and trust.
“When I first went there [Cunnamulla] I didn’t even see a patient.
“I just went there to meet the people, to meet the elders and just introduce myself and tell them where I’m from.”
Centre of excellence
Back in Brisbane, Waka Waka and Kalkadoon man Dr Hayman is best known as the founder/director of the Inala Indigenous Health Service.
As at Cunnamulla, his ethos at Inala has always been to listen to what the community needs, beginning in 1995 with an informal consultation to find out why there were only 12 Indigenous patients attending the clinic.
He listened and, nearly 20 years later, this month sees the official opening of Dr Hayman’s new $7 million Inala Centre of Excellence with more than 6000 Indigenous patients on the book.
Again, the integration of specialists in the primary care setting has been part of Inala’s clinical success.
“We saw that a lot of our patients just weren’t turning up to outpatients for a whole gamut of reasons”, Dr Hayman says.
“A lot of Aboriginal people distrust the hospitals. Transport’s a big problem — a lot don’t have cars. A lot have other family business or something’s going on. It’s family first, not the appointment.”
He began asking medical specialists if they would come to Inala to see patients rather than the patients having to go elsewhere to see them.
Today, they have a group of regular visiting specialists including Dr Wang and Dr Russell along with paediatrician Dr Karen Liddle, ophthalmologist Dr Rowan Porter and, most recently, hepatologist Dr Paul Clark.
The clinic has also acquired tools to help the visitors — making it possible to do echocardiograms, retinal photographs and other diagnostic tests onsite.
There is now a plan to even begin providing interferon treatments at the clinic in an effort to turn around a very low treatment rate for hepatitis C — just five patients since the service was established in the mid-nineties.
All about relationships
Dr Ross Bailie has been examining specialist outreach in both remote and urban Indigenous communities for more than a decade.
Like Dr Hayman, he says good relationships — with both the community and with the required specialists — are vital for the success of outreach programs and, for this reason, they often work best when coordination is done by primary care providers such as at Inala.
“They have a location where there is a range of specialists living reasonably nearby and there’s a very effective leader at Inala”, Dr Bailie says.
“He [Dr Hayman] has been able to develop those relationships with the specialists and bring in people and find ways to make sure that it meets his patients’ needs but also that it suits
Dr Bailie is one of the authors of the National Sentinel Sites evaluation of the ICDP.
“There are many examples where it’s been done well and there are others where it could be done better”, the senior principal researcher with the Menzies School of Public Health says.
He puts Inala in the former category together with Tharawal Aboriginal Medical Services in southwest Sydney.
“It’s much more challenging in regional and remote locations where specialists have to travel and where there’s a relative shortage of specialists and they’ve really got to find the right people.”
It is also difficult when the service is arranged for the convenience of the providers rather than the patients or frontline staff, cautions Dr Bailie.
The final report produced as part of the Sentinel Sites evaluation is now with the government although it remains unclear how long it will be until it is released and what the response may be.
Given the success at Inala Indigenous Health Service, the Cunnamulla clinic and elsewhere, those involved are hoping that the recent boost to Closing the Gap funding, from $200 million to $260 million per year, will see more money allocated to take specialist outreach to more Indigenous communities around the country.
Outreach and coordination
Even when a specialist is able to visit a community as part of an outreach program, there are many reasons why Indigenous patients may be unable to attend appointments.
Transport is often a serious problem; trust can be another, as can childcare, scheduling and the environment.
When the Western NSW Medicare Local (WNML) looked at improving Indigenous chronic disease health services in the NSW central west regional town of Bathurst, they sought to address this by not only bringing in visiting specialists to operate out of a primary care environment, but also setting up a care coordination program to help as many people as possible attend the weekly clinics.
It has been a huge success.
“Not to be dramatic about it, but when I talk to the nurses doing the care coordination, they are absolutely convinced that there are people alive today that wouldn’t be if it wasn’t for what they are doing”, director of clinical services at WNML Bryan Hoolahan says.
The Medicare Local’s care coordinators — partly funded by the ICDP — provide practical assistance ranging from reminders about appointments to help with solving childcare issues and arranging transport where required for Indigenous people with chronic disease.
The program is so effective in reducing hospital admissions — by as much as 30% — and improving the quality of life of patients that the WNML has been able to secure extra funding for an additional four care coordinators.
“We’re actually building our workforce at the moment trying to really stretch out into the western sector.”
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