ama queensland junior doctor · pdf fileama queensland junior doctor conference better access...

AMA Queensland Junior

Doctor Conference

Better access and equity in health for Aboriginal and Torres Strait Islanders: Caring for Indigenous patients

and what you need to know as a junior doctor

Saturday 27 June 2015

Associate Professor Noel Hayman

Indigenous Population Profile

State

Indigenous population

Proportion of Indigenous

population %

Proportion of total State/Territory

population %

NSW 172,624 31.5 2.5

Qld 155,825 28.4 3.6

WA 69,665 12.7 3.1

NT 56,779 10.4 26.8

Vic 37,991 6.9 0.7

SA 30,431 5.5 1.9

Tas 19,625 3.6 4.0

ACT 5,184 0.9 1.5

TOTAL 548,370 100.0 2.5

ABS - June 2011

AMA Queensland Junior Doctor Conference

Better access and equity in health for Aboriginal and Torres Strait Islanders: Caring for Indigenous

patients and what you need to know as a junior doctor


Diversity of Aboriginal Culture





Indigenous Australians younger by an average of 14years

Indigenous median age 20years

Non-Indigenous median age 34years

40% of Indigenous population are aged less than 15years compared

to 21% of the total Australian population

2.6% of Indigenous population 65years compared with 12% total

population

Northern Territory 2/3 Indigenous population live in rural remote, 1/3

urban areas

Queensland 1/3 Indigenous population live in rural remote, 2/3 urban

areas

Population profile and distribution impact greatly on Quality Health

Service Delivery





Inala Community Health Building – Indigenous Health resides in this building

Access data to Inala Health Centre General Practice





Improving Indigenous access to a mainstream health service

• Intervention Location

• Inala – Urban multicultural population

• Inala – 8% Indigenous but only 12 Indigenous patients attended UGP

Services Provided at Inala Community Health Centre • Inala Health Centre General Practice (UGP-IHCGP – IPC)

• Inala Indigenous Health Service established in 1995

• Home & Community Care (HACC)

• Child Health (visiting pediatricians)

• Oral Health

• Mental Health (visiting psychiatrists)

• Alcohol, Tobacco & Other Drugs

• Breast screening Unit

• Therapies

Noel Hayman, Nola White and Geoffrey Spurling. Improving Indigenous patients’ access to mainstream health services: The Inala experience. Medical Journal of Australia (MJA), 2009; 190 (10): 604-606

Access to Primary Health Care-very import health issue for

Aboriginal and Torres Strait Islander people





Improving Indigenous access to a mainstream health service

Data from focus group and phone interviews 1994.

Reasons for not attending IHCGP:

• No Aboriginal person working within the centre

• Aboriginal people perceived staff as unfriendly & uncaring

• Staff talk down to you “Make you feel shamed”

• Staff body language was interpreted by aboriginal people as unwelcoming

• Treated poorly at reception eg: “Why are you coming in at 4.30 pm, we

close at 5.00pm. Go home and come back tomorrow”.

• Staff showed low tolerance to indigenous child behaviour “keep them

quiet’.

• Long wait to see doctor

• There is “nothing” at the centre that aboriginal people can identify with.

Reasons for attending IHCGP (UGP):

• Convenience

• Satisfied with doctors & Staff

• No racism reported and patients older





Five key strategies to improve indigenous access

Strategy 1

To Employ an Aboriginal or Torres Strait person in IHCGP. This person could be a nurse, Aboriginal or

Torres Strait Islander Health Worker, a receptionist , or a liaison person for the centre.

Strategy 2

To purchase culturally appropriate health posters and artifacts for the center to help make Aboriginal &

Torres Strait Islanders people “feel more at home”. Also play Aboriginal radio “AAA Murri Country” on

occasions. This will enable Aboriginal & Torres Strait Islander people to identify with the centre.

Strategy 3

To provide cultural awareness talks to all staff within the centre.

Strategy 4

To disseminate information into the Aboriginal and Torres Strait Islander community about what

services are available at the Inala Community Health Centre.

Strategy 5

To promote intersectoral collaboration:

Woolloongabba Aboriginal & Islander Community Health Service (AICHS) to conduct a clinic within

IHCGP.

Liaison with the Inala Aboriginal & Torres Islander Women’s Health Support Group

Attend Aboriginal & Torres Strait Islanders Inter-Agency meetings.

Striving Towards a Centre of Excellence in Indigenous Primary Health Care





IHCGP (UGP) 1994 IIHS 2006-2013





Inala Indigenous Health Clinic

and patient waiting area 2006-2013





Benefits from Access Data

Funding from Queensland Health limited: Access to section 19(2) Health Act.

Increase in staff

1995 – Staff

Doctor 1.0 Doctor

Nurse 1.0 Nurse

2012 – Staff

Doctor 2.5 VMO

3.0 SMO

1.0 GP Registrar

0.25 Ophthalmologist

0.25 Cardiologist

0.25 Endocrinologist

0.3 Paediatrician

Nurse 1.0 NUM

4.0 Child Health Nurses

3.0 Clinical Nurses

1.0 Chronic Disease Co-ordinator

0.4 Outreach Immuniser

3.0 Research Nurses (Aboriginal)

Research Director 1.0 Research Director

Research and Teaching Manager 1.0 Research and Teaching Manager

AHW 4.0 Aboriginal Health Worker

Dietician 1.0 Dietician- Clinic

Nutritionist 1.0 Nutritionist- Community

Project Officers 14.0 Research associated project officers

Administration 5.0 Administration Officers

Total FTE’s Over 50 staff in 2014





Benefits from Study

• Indigenous people finding it easier to access Mainstream Health Services.

1995, 12 patients: 2014 over 10,000 on data base with approximately 3,000 regular patients

• Culture exchange with other Doctor’s

• Screening and early detection of Chronic diseases

• High immunisation rates (children)

• Employment of more staff (Under Section 19 (2) of the Health Act)





Lessons Learnt Over Past 20 years

• Local Aboriginal & Torres Strait Islander people attend because staff is Indigenous

• Importance of Aboriginal Doctors and Nurses:

– Easy to talk to

– Knowledge of culture

– Explain medical terminology

• Importance of working with community





Healthy for Life 2006 - 20011

• Commonwealth funding commencing 2006

• Healthy for Life $102.4 M over four years

• Improve health outcomes for mums and babies

• Reduce incidence of chronic disease

• Enhance the life of patients with chronic disease

• Extensive evaluation framework

• CQI, collect data, analyse, act





Chronic Disease - NIDDM Clients Average HbA1c 06/07 - 9.6%, 07/08 - 8.2%,

08/09 - 7.9%, 10/11 - 7.9%, 12/13 - 8.0%

2006-

2007

2007-

2008

2008-

2009

2010-

2011

2012-

2013

•9.6% •8.2% •7.9% •7.9% •8.0%





My Vision

Over the past 5-6 years

Centre of Excellence in Indigenous Primary Health Care (Indigenous Health: Everyone’s responsibility)

• Link with Universities for Teaching (medical students, nursing, Allied Health) and Research

• Link with Colleges: Teaching and training of Advanced Trainees (ie Paeds, Endocrine, Psychiatry, GP registrar) in Indigenous Health

• Improve local community capacity

• Teaching of PGY1 (Interns) eg Chronic Disease management

• Outreach to areas of need where access is poor. Cunnamulla MSOAP-IDC.

• Staff from DG’s office at one of my conference presentations: invited to meet Health Minister.

Equity to Infrastructure





Centre Of Excellence

Workforce Development

• Strong cultural exchange

• Strong grounding In Indigenous Health Issues

• Strong teaching in Chronic Disease Management

• Strong leadership (Succession planning)

• Outcomes: 3 GP Registrars - now SMO’s with strong interest in teaching and research

• Advanced Paediatrician Fellow – now our Paediatrician (Completed MPH in Indigenous Child Health)

• Integration of Specialist services at Inala

Cardiology, Ophthalmology, Endocrinology, Hepatology, Paeds.

• Very low turnover of staff (Doctors have half day off from clinic for research or what ever)





Centre Of Excellence

Research

• Identify community areas of concern

• Building up the evidence base in Indigenous Primary

Health Care settings

• Provide a culture for Research Excellence

• Develop Indigenous Researcher’s capacity: Opportunity

for more PhD’s and Master’s for Indigenous researcher’s

at Inala

• Research – the best way to tackle emerging issues





Centre of Excellence

Research

Since commencement of Centre of Excellence: 2009

• Over 40 peer reviewed research publications

• 65 conference presentations: national & international

• 8 nationally competitive research grants

• 1 PhD student enrolled

• 2 Novice Researcher Fellowships won





Inala Aboriginal and Torres Strait Islander Community Jury for

Health Research

• Provides cultural oversight to IIHS research

• All research done at or through IIHS needs approval from the

Jury

• Researchers have to present their research to the Jury, in plain

English, focusing on the benefit for the community

• 14 members, range of ages, males & females, Aborigines and

Torres Strait Islanders

• Currently research project evaluating the experiences of the

jury members and the researchers who have presented to the

jury





Inala Indigenous Health COE

Patient Waiting Area May 2013

MJA publication Indigenous issue 2014





Centre of Excellence at Completion





Inala Indigenous Health Clinical & Specialist Area

OPHTHALMOLOGY TREATMENT AND MINOR OPS

CARDIOLOGY CLINICAL AREA





Indigenous Health Checks:

Why Bother?

Medical Journal of Australia (MJA), 2009; 190 (10): 562-564

Spurling GK, Hayman NE, Cooney AL. Adult health checks for

Indigenous Australians:

the first year's experience from the Inala Indigenous Health

Service.





Level of Evidence Intervention

Level 1 evidence Brief smoking cessation advice

Identification of depression and

suicidal ideation

Identification of diabetes

Immunisation

Level II – III evidence Pap smears

Identification and treatment of

Chlamydia

Benefits of Interventions

Evidence in Health Checks





Health Check as a Screening Tool

Inala Indigenous Health Adult Health

Check

Other Screening Intervention

One new case of diabetes for every 26

Indigenous people screened

Ausdiab: One new case of diabetes

for every 32 Indigenous people

screened

One pap smear abnormality for every

9 pap smears

North Qld Urban Indigenous clinic

screening program: One pap smear

abnormality for every 12 pap smears

One case of Chlamydia for every 20

adult health checks (in women)

North Qld Urban Indigenous clinic

screening program: One case of

Chlamydia for every 21 people

screened





Proportion of Overweight / Obese children presenting to

Inala Indigenous Health

Child Health Checks (n=335, ages 2-14)

2 to 5 (n=114) 6 to 10 (n=134) 11 to 14 (n=87)

Overweight (%) 7 8 9

Obese (%) 2 12 30

Combined (%) 9 30 39

Proportion of Overweight/ Obese Children

presenting to Inala Indigenous Health Service

0

10

20

30

40

50

Pro

po

rtio

n (

%)

Overweight (%) 7 8 9

Obese (%) 2 12 30

Combined (%) 9 30 39

2 to 5 (n=114) 6 to 10 (n=134) 11 to 14 (n=87)





The Future of Health Checks at Inala Indigenous Health

• Dedicated database for health checks (ERIC)

• Electronic forms

• Enter the information at the point of care

• Self-populate the problem list

• Interrogate data, Doctor completing PhD

• Guide service delivery and interventions eg smoking 67% in

2009. 60% in 2011. 52% in 2014.





Closing the Gap Programs

Closing the Gap $1.6B over four years

• MSOAP-ICD (Medical Specialist Outreach Assistance Program-

Indigenous Chronic Disease) new money (Cunnamulla)

• MSOAP-existing money

• USOAP (Urban) new money

• PIP incentives (Practice accreditation)

• CTG PBS co-payment. Indigenous patients with chronic disease. If they pay full price, now they pay $5.80 per script. If they pay $5.80 per script, now medication is free. To compliment S100 in rural/remote.





Cunnamulla Outreach Clinic at Postcode 4490

• OUTREACH- Length of MSOAP-ICD to Cunnamulla– approximately 4 years.

• Classified Remote

• Population at 2011 census 1641

• Large percentage Aboriginal 33.9%

• Have 355 patients registered, 64% of population. Do not see children. Chronic disease program.

• No resident GP at Cunnamulla for 8 years

• Cunnamulla: Aboriginal word for long stretch of water ( lies on the Warrego River)

• Traditional Owners: Kooma





Multi- disciplinary

Team

– Dr Noel Hayman – GP/Public Health Physician

– Dr Tony Russell – Endocrinologist (PAH)

– Dr William Wang – Cardiologist (PAH)

– Nola White – Nurse

– Desley Deshong – Nurse

– Tarah Brown - Admin





Total Doctor consultations 2013-2014

• 871 GP consultations (Total 2451)

• 175 Specialist consultations (Total 416)

• Total 1046 doctor consultations (Total 2867)

• Currently average 87 doctor consultations per

monthly visit





Inala Inala Inala C’mulla C’mulla C’mulla

11/12 12/13 13/14 12/13 11/12 13/14

New patients 40 54 80 14 46 61

Reviews 11 27 59 8 36 53

ECG 27 37 42 16 50 61

Exercise Stress Test - - 75 - 21 17

Echo 47 49 47 29 71 42

Cardiology





Reporting 15-4-2012 to 15-4-2013 Annual Diabetic Cycle of Care

Cunnamulla COE

Annual Diabetic Cycle of Care 54 149

Females 33 (61%) 72 (48%)

Average age 57 55

Examination Findings

Average BMI 34.8 36.7

Average Systolic BP 131 131

Average HbA1c 7.90% 8.20%

Average AC ratio 8.2 13.8

Drug Use

Smoking 15 (28%) 54 (36%)

Insulin use 12 (22%) 41 (28%)

Annual Diabetic Cycle of Care





The Future for Cunnamulla • Importance of screening (more younger age group)

• Early detection and intervention/treatment (every 22 health checks new diabetic diagnosed)

• Retinal screening (Teach Health Workers to take photo) now in place, via store and forward. Please to report AMAQ Foundation secured funded for retinal camera. Wm Buck donation.

• Recently won NHMRC CRE in Telehealth

• Smoking

• Obesity

• ? Additional services ? Hepatology (Gastro) ? Ophthalmology ? Addiction medicine





Centre of Excellence at Completion





?

To improve Indigenous health we need new models of care. The

COE at Inala is and excellent model focusing on the integration of

specialist services,

teaching and research as well as high quality care with health

gains for our community (shown by CQI)





Take Home Points • Diversity of Culture

• Know your community

• Mental health issues common

• Screen for chronic disease

• Chest pain in the young ? Heart disease

• Vaccinations Fluvax and Pneumovax.

• Stay engaged, work with patient, do not be condescending

• Use Aboriginal Health Workers

• Integration of specialist care, one stop shop, will improve attendance

• Questions ?





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