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KPMGNational Monitoring and Evaluation of the Indigenous Chronic Disease PackageBaseline Report (2009-10)

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National Monitoring and Evaluation of the IndigenousChronic Disease Package

Baseline Report(2009-10)

The evaluation of the Indigenous Chronic Disease Package was commissioned by the Department of Health. This evaluation report has been prepared by KPMG Australia.The report’s lead authors were the National Health and Human Services Practice, KPMG.The other major contributors to the report were: WinangaliKPMG wishes to acknowledge the following stakeholders for their contribution to the evaluation through giving their time and sharing their experiences: the Department of Health, state and territory health departments, the National Aboriginal Community Controlled Health Organisation and its Affiliates, peak bodies, Indigenous Health Services, Divisions of General Practice/Medicare Locals, the Indigenous Health Partnership Forums, ICDP workers and their fund holder representatives, general practice staff and community members. Please refer to Appendix B for a full list of stakeholders consulted.CitationKPMG 2013, National Monitoring and Evaluation of the Indigenous Chronic Disease Package Baseline Report 2009-10, Australian Government Department of Health, Canberra

iKPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with

KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional

Standards Legislation.



Table of ContentsNational Monitoring and Evaluation of the Indigenous Chronic

Disease Package Baseline Report (2009-10) 1List of Figures and Tables iiiDisclaimer viiGlossaryviii1.Executive summary 22.Introduction 73.Contextual baseline 154.Whole of ICDP baseline 225.National Action to Reduce Indigenous Smoking Rates 406.Helping Indigenous Australians Reduce Their Risk of Chronic Disease 627.Local Indigenous Community Campaigns to Promote Better Health

708.Subsidising PBS Medicine Co-payments 819.Higher Utilisation Costs for MBS and PBS 9310.Supporting Primary Care Providers to Coordinate Chronic Disease Management9911. Supporting Primary Care Providers to Coordinate Chronic Disease Management 11312. Improving Indigenous participation in health care through chronic disease self management 12513.Increasing Access to Specialist Care 13514.Increasing Access to Specialist and Multidisciplinary Team Care

14715.Workforce Support, Education and Training15916. Expanding the Outreach and Service Capacity of Indigenous Health Organisations 17417. Engaging Divisions of General Practice to Improve Indigenous Access to

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Mainstream Primary Care 18718.Attracting More People to Work in Indigenous Health20019.Clinical Practice and Decision Support Guidelines 214

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List of Figures and TablesFigure 1: Overarching ICDP causal pathway. Source: KPMG...............................31Figure 2: Estimates of the proportions of Aboriginal and Torres Strait Islander people that are current smokers, 2002-2008.....................................................48Figure 3: Percentage of Aboriginal and Torres Strait Islander women who smoked during pregnancy, 2006-2008...............................................................49Figure 4: Tackling Smoking measure causal model. Source: KPMG....................53Figure 5: Nicotine dependence items supplied under S100 RAAHS Supply Program arrangements – by month, Jul 2008 – May 2010..................................58Figure 6: HLW measure causal model. Source: KPMG........................................66Figure 7: LCC causal model. Source: KPMG........................................................78Figure 8: PBS Co-payment measure causal model. Source: KPMG.....................89Figure 9: Number of health assessments provided to Aboriginal and Torres Strait Islander people (MBS items 704, 706, 708, 710 and 715) and number of unique providers (i.e., medical practitioners) by Medicare quarter................................93Figure 10: Number of health assessments provided to Aboriginal and Torres Strait Islander people (MBS items 704, 706, 708, 710 and 715) by Medicare quarter and jurisdiction......................................................................................94Figure 11: Number of health assessments provided to Aboriginal and Torres Strait Islander people (MBS items 704, 706, 708, 710 and 715) by Medicare quarter and remoteness.....................................................................................94Figure 12: Number of follow up services (Item 10987) and unique providers by Medicare quarter................................................................................................96Figure 13: Number of services provided to Aboriginal and Torres Strait Islander people (MBS items 81300 to 81360) by Medicare quarter, for selected allied health workers....................................................................................................97Figure 14: PIP Indigenous Health Incentive causal model. Source: KPMG........107Figure 15: CCSS measure causal pathway model. Source: KPMG....................122Figure 16: Chronic Disease Self Management measure causal model. Source: KPMG................................................................................................................132Figure 17: Governance of the USOAP (B5a measure).......................................138Figure 18: USOAP measure causal model. Source: KPMG................................143Figure 19: MSOAP-ICD causal model. Source: KPMG........................................155Figure 20: Workforce Support, Education and Training causal model. Source: KPMG................................................................................................................169Figure 21: Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure causal model. Source: KPMG...............................182

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Figure 22: Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care causal model. Source: KPMG...............................196Figure 23: Attracting More People to Work in Indigenous Health (C4) measure causal model. Source: KPMG............................................................................208Figure 24: Aboriginal and Torres Strait Islander vocational education students enrolled in health disciplines across Australia, 2008-10...................................212Figure 25: Aboriginal and Torres Strait Islander university students enrolled in health disciplines..............................................................................................213Figure 26: Clinical Practice and Decision Support Resources measure causal model. Source: KPMG.......................................................................................221

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Table 1: Overview of ICDP measures. Source: National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan Jurisdiction: Commonwealth.................................................................................9Table 2: Broad analysis of linkages and crossovers between state and territory implementation plans under the Closing the Gap in Indigenous Health Outcomes, and the ICDP....................................................................................20Table 3: Relevant stakeholder groups and their role in the ICDP as a whole.... .22Table 4: Key stakeholders, roles and communications in relation to the National Action to Reduce Indigenous Smoking Rates (A1) measure...............................43Table 5: Nicotine replacement medicines supplied under the S100 RAAHS Supply Program, by state/territory. ,,..................................................................58Table 6: Number of services using OSR which reported providing tobacco use treatment and prevention programs: by service type, program type and year; 2008-09 to 2009-10............................................................................................59Table 7: Key stakeholders and roles in the LCC (A3) measure...........................74Table 8: Key stakeholders and roles...................................................................83Table 9: Average number of health assessments provided to Aboriginal and Torres Strait Islander people ((MBS items 704, 706, 708, 710 and 715) per unique provider by remoteness for May 2010 Medicare quarter, for selected jurisdictions........................................................................................................94Table 10: National MBS expenditure in 2009-10 on specific items.....................96Table 11: Key stakeholders and roles in relation to the PIP Indigenous Health Incentive measure............................................................................................102Table 12: Number of practices registered, patients registered for the PIP Indigenous Health Incentive payments as at May quarter 2010 by practice type.......................................................................................................................... 110Table 13: Number of practices registered, and patients registered for the PIP Indigenous Health Incentive payments as at May quarter 2010 by remoteness and service type...............................................................................................110Table 14: Number of anticipated and actual practices registered for the Indigenous Health Incentive, 2009-10..............................................................110Table 15: Key stakeholders and roles in relation to the CCSS measure...........115Table 16: Key stakeholders and roles in relation to the Chronic Disease Self Management (B4) measure..............................................................................127Table 17: Key stakeholders and roles...............................................................137Table 18: 2009-10 performance for USOAP (B5a) measure quantitative indicators.........................................................................................................145Table 19: Key stakeholders and roles in relation to the MSOAP-ICD (B5b) measure...........................................................................................................148

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Table 20: Actual performance for MSOAP-ICD measure indicators, 2009-10....156Table 21: Key stakeholders and roles in relation to the Workforce Support, Education and Training (C1) measure..............................................................162Table 22: Expenditure, Workforce Support, Education and Training (C1) measure 2009-10. *Note: budget and expenditure as per calendar year.......................171Table 23: 2009-10 performance for Workforce Support, Education and Training (C1) measure activities on Commonwealth Implementation Plan indicators....172Table 24: Key stakeholders and roles in relation to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure.........176Table 25: 2009-10 funded and actual recruitment for Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2)........................183Table 26: OSR selected primary health care service statistics by service type for 2008-09 and 2009-10.......................................................................................184Table 27: 2009-10 actual expenditure for Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure............................185Table 28: Key stakeholders and roles in relation to the Improving Access to Mainstream Primary Care (C3) measure..........................................................190Table 29: 2009-10 performance of the Improving Access to Mainstream Primary Care (C3) measure against Commonwealth Implementation Plan indicators...198Table 30: Key stakeholders and roles in relation to the Attracting More People to Work in Indigenous Health (C4) measure.........................................................202Table 31: Selected OSR statistics on vacancies in community controlled IHSs.......................................................................................................................... 210Table 32: Key stakeholders and roles in relation to the Clinical Practice and Decision Support Guidelines (C5) measure......................................................215

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DisclaimerInherent LimitationsThis report has been prepared as outlined in the scope section. The services provided in connection with this engagement comprise an advisory engagement which is not subject to Australian Auditing Standards or Australian Standards on Review or Assurance Engagements, and consequently no opinions or conclusions intended to convey assurance have been expressed.

This report has not been prepared on KPMG letterhead and does not contain the KPMG logo, but is presented in an editable format to support web accessibility for the vision impaired. We confirm that the definitive version of this report is that which bears the KPMG logo.

The findings in this report are based on consultation with stakeholders.

No warranty of completeness, accuracy or reliability is given in relation to the statements and representations made by, and the information and documentation provided by the Department of Health personnel and stakeholders consulted as part of the process.

Where appropriate KPMG have indicated within this report the sources of the information provided. We have not sought to independently verify those sources unless otherwise noted within the report.

KPMG is under no obligation in any circumstance to update this report, in either oral or written form, for events occurring after the report has been issued in final form.

The findings in this report have been formed on the above basis.

Third Party RelianceThis report is solely for the purpose set out in the scope section and for the information of the Department of Health, and is not to be used for any other purpose or distributed to any other party without KPMG’s prior written consent.

This report has been prepared at the request of the Department of Health in accordance with the terms of KPMG’s contract. Other than our responsibility to the Department of Health neither KPMG nor any member or employee of KPMG undertakes responsibility arising in any way from reliance placed by a third party on this report. Any reliance placed is that party’s sole responsibility.

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GlossaryAcronym Description

ABS Australian Bureau of Statistics

ACCHO Aboriginal Community Controlled Health Organisation (the term Indigenous health service (IHS) is more commonly used in this report)

AGPN Australian General Practice Network (as of 1 July 2012 known as the Australian Medicare Local Alliance)

AHW Aboriginal Health Worker

AIHW Australian Institute of Health and Welfare

AMS Aboriginal Medical Service (the term Indigenous health service (IHS) is more commonly used in this report)

APCC Australian Primary Care Partnerships

ATSIHTP Aboriginal and Torres Strait Islander Health Training Posts

ATSIOW Aboriginal and Torres Strait Islander Outreach Worker (an ICDP funded position)

Care Plan/care planning

A care plan refers to a plan developed by a GP to manage a patient’s chronic disease, usually a GP Management Plan (GPMP) and/or Team Care Arrangement (TCA)

CATSIN Congress of Aboriginal and Torres Strait Islander Nurses

CEITC Centre for Excellence in Indigenous Tobacco Control

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Acronym Description

CEO Chief Executive Officer

CO Central Office (of the Department of Health and Ageing)

COAG Council of Australian Governments

CCSS Care Coordination and Supplementary Services (Program) – the name usually used when discussing the Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3b) measure

CDSM Chronic disease self management

CHAP Community Health Action Pack

CRI Cue and Response Interview

CtG scripts Closing the Gap scripts (prescriptions annotated with CtG by participating practices for eligible patients to access concessional or free PBS medicines under the Subsidising PBS Medicine Co-Payments (B1) measure)

DEEWR Department of Education, Employment and Workplace Relations

DHS Department of Human Services (now includes Medicare Australia)

Divisions of General Practice

Within this report the term Divisions of General Practice is used. This may include those Divisions which have recently transitioned to Medicare Locals

FaHCSIA Australian Government, Department of Families, Housing, Community Services and Indigenous Affairs

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Acronym Description

FTE Full Time Equivalent

GP General Practitioner

GPET General Practice Education and Training Ltd

GPMP General Practice Management Plan. Refers to MBS item 721 prepared for patients who have a chronic medical condition and complex care needs

H4L Healthy for Life (program)

HbA1c Glycated haemoglobin (a measure of glucose present in blood)

HLW Healthy Lifestyle Worker (an ICDP funded position)

HPF Health Performance Framework

IAHA Indigenous Allied Health Australia

ICDP Indigenous Chronic Disease Package

IHPF Indigenous Health Partnerships Forum

IHPO Indigenous Health Project Officer (an ICDP funded position)

IHS Indigenous health service. Within this report IHS is used to describe any health service which primary provides services to Aboriginal and Torres Strait Islander people, regardless of status as a community controlled or government funded entity.

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Acronym Description

Ipsos SRI Ipsos Social Research Institute

KPI Key Performance Indicator

LCCs Local Community Campaigns (Local Indigenous Community Campaigns to Promote Better Health (A3)

MBS Medicare Benefits Schedule

MSIA Medical Software Industry Association

MSOAP-ICD Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease

NACCHO National Aboriginal Community Controlled Health Organisation

NAGATSIHID National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data

NAHSSS Nursing and Allied Health Scholarship and Support Scheme

NATSIHEC National Aboriginal and Torres Strait Islander Health Equality Council

NATSIHS National Aboriginal and Torres Strait Islander Health Survey

NATSISS National Aboriginal and Torres Strait Islander Social Survey

NBCSP National Bowel Cancer Screening Program

NCVER National Centre for Vocational Education and Research

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Acronym Description

NHRA National Health Reform Agreement

NIRA National Indigenous Reform Agreement

NPDC National Perinatal Data Collection

NPA National Partnership Agreement (on Closing the Gap in Indigenous Health Outcomes)

NSFATSIH National Strategic Framework for Aboriginal and Torres Strait Islander Health

NTAHKPI Northern Territory Aboriginal Health Key Performance Indicator

NTER Northern Territory Emergency Response

OATSIH Office for Aboriginal and Torres Strait Islander Health

OSR OATSIH Services Reporting

PIH Partners in Health

PBS Pharmaceutical Benefits Scheme

PIP Practice Incentives Program

PSA Pharmaceutical Society of Australia

PGA Problems and Goals Assessment

QAIHC Queensland Aboriginal and Islander Health Council

xiiiKPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with





Acronym Description

QUMAX Quality Use of Medicine in Aboriginal and Torres Strait Islander People program

RAAHS Remote Area Aboriginal Health Service

RACGP Royal Australian College of General Practitioners

RCNA Royal College of Nursing Australia

RN Registered Nurse

RSE Relative Standard Error

RTCs Regional Tobacco Coordinators

RTSHLTs Regional Tackling Smoking and Healthy Lifestyle Teams (ICDP funded positions)

S100 RAAHS Supply Program

Supply of pharmaceutical benefits to remote area Indigenous Health Services under section 100 of the National Health Act 1953 (Cth)

SBOs State Based Organisations (of the Divisions of General Practice)

SONT Specialist Outreach Northern Territory

SSE Sentinel Sites Evaluation

STO State and Territory Office (Department of Health and

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Acronym Description

Ageing)

TAWs Tobacco Action Workers (ICDP funded positions)

TCA Team Care Arrangements (MBS item 723)

the department The Department of Health and Ageing

the Guild Pharmacy Guild of Australia

the Package Throughout this report used to refer to the Indigenous Chronic Disease Package

TRG Technical Reference Group (PBS Co-payment measure)

USOAP Urban Specialist Outreach Assistance Program

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1. Executive summaryThis document is the Baseline Report for the evaluation of the Indigenous Chronic Disease Package (ICDP or ‘the Package’). The purpose of the report is to form a baseline view of the ICDP against which further findings will be considered and assessed, and to provide information on the first year of implementation (2009-10).The ICDP is the Australian Government’s contribution to the National Partnership Agreement (NPA) on Closing the Gap in Indigenous Health Outcomes. The NPA was agreed in November 2008. The Package is being managed by the Department of Health and Ageing (the department).1.1 Baseline progressThe ICDP comprises a set of 14 interrelated measures that include a range of health promotion and social marketing activities, reforms to existing programs, and new initiatives and funding to increase the size and capacity of health care services to deliver effective care to Aboriginal and Torres Strait Islander people. These measures each fit within one of the three key priorities that have been identified for the ICDP: tackling chronic disease risk factors; primary health care services that deliver and fixing the gaps and improving the patient journey. The ICDP represents a significant investment, with a total of $805.5 million to be distributed over the first four years (2009-2013). Implementing such a large and complex package of diverse initiatives across a broad spectrum of health-related areas is a significant achievement in itself. Individual measures stayed largely on track in terms of timelines and funding expenditure during 2009-10. Where slippage in timeframe or budget did occur, the department applied a flexible approach to managing delays and expenditure allocations budget over (or under) spends in a manner which supported the ongoing implementation of the Package overall. Important achievements in 2009-10 which apply across multiple outcomes areas and measures: the commissioning of developmental research for various measures1 which

proved beneficial in shaping the underlying strategies; undertaking extensive internal and external consultations for most measures,

and the establishment or utilisation of various expert reference groups and oversight bodies to guide the implementation of various measures;

progress towards realising the extensive workforce elements of the ICDP that are relevant to several measures. Particularly, significant progress was made within the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure, which saw the recruitment

1 National Action to Reduce Indigenous Smoking Rates (A1), Local Indigenous Community Campaigns to Promote Better Health (A3) and Attracting More People to Work in Indigenous Health (C4).

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of 128 Indigenous Health Project Officers (IHPOs) and Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs); and

progress towards implementing the Sentinel Sites Evaluation project.Some measures progressed rapidly to the point of providing services and creating material outputs within their first year of operation, these included: implementation of the Practice Incentives Program (PIP) Indigenous Health

Incentive and commencement of payments to practices according to the incentive scheme;

contracting Flinders University to provide the Chronic Disease Self Management training program under the Improving Indigenous Participation in Health Care through Chronic Disease Self Management (B4) measure, and commencement of training in April 2010;

commencement of outreach services, particularly in regional and remote areas under the Increasing Access to Specialist and Multidisciplinary Team Care (B5) measure;

the roll out of additional placements for the GP registrar training posts under the Workforce Support, Education and Training (C1) measure;

the change allowing Aboriginal and Torres Strait Islander people to receive a maximum of 10 follow up services per year from a practice nurse or registered Aboriginal Health Worker following a health assessment, rather than the previous maximum of five; and

recruitment of IHPOs and ATSIOWs in both Indigenous health services and mainstream organisations.2

Other measures focused on preparing for implementation in 2010-11. Some particularly important developments included: negotiating funding arrangements which allowed recruitment of workers to

progress early in 2010-11. This is relevant to the National Action to Reduce Indigenous Smoking Rates (A1) and Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) measures;

for the PBS Co-payment measure (B1), development of prescriber and pharmacy software to accommodate the Closing the Gap (CtG) scripts3, and promoting the initiative;

the execution of funding agreements to manage the Care Coordination and Supplementary Services program4 in each state and territory;

2 Relevant to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measures. 3 The scripts which have been annotated to allow access to the co-payment subsidy are commonly referred to as ‘CtG scripts’. The measure is sometimes referred to as the CtG scripts measure by providers.4 Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3b) measure.






procurement to engage a consultant to develop the Do Something Real campaign for the Attracting More People to Work in Indigenous Health (C4) measure; and

a review of the literature and existing guidelines, tools and resources which resulted in a changing focus for the Clinical Practice and Decision Support Guidelines (C5) measure to collating existing resources rather than developing new resources to support clinical practice.

Three main themes were evident from the consultations with external stakeholders and in some cases, internal stakeholders. The evaluation will explore these themes further through ongoing project activities. These themes were: The need for an explicit strategy and plan to build and sustain the workforce

aspects of the ICDP, given how extensive and central the workforce elements are to the longer term aims of ICDP.

The overall approach to stakeholder engagement, which was consistently raised as a concern during consultations. It is difficult for the evaluation to form an objective view of whether or not there was sufficient consultation with stakeholders during the design and planning phase, particularly in the context of the constraints imposed by timeframes and the budget approval process. However, the evaluation has identified various ways in which Aboriginal and Torres Strait Islander people have been engaged in the implementation of the ICDP at the national, jurisdictional and community level.

The need for flexibility in how individual measures, for example the workforce based measures, can be applied at the local level, balanced against the need to deliver on the objectives of the individual program.

It is important to note that all stakeholders support the overarching design and intent of ICDP. The focus on chronic disease as a means to address the gap in life expectancy is seen to be appropriate and important. Stakeholders identified some opportunities to strengthen the ICDP going forward, including through: An ongoing role of the Indigenous Health Partnership Forums (IHPFs) to

provide advice and local insights to ensure the measures are implemented in a manner which is both consistent with the design and locally appropriate.

Supporting funded organisations (and representative and peak bodies) to apply flexible local solutions while ensuring the focus of the funding is maintained (that is, a focus on outcomes rather than processes).

Identifying and strengthening linkages across measures and with other initiatives to minimise duplication and to maximise cross-measure support and synergies.

1.2 Key findings against the evaluation objectives A set of key objectives were identified and agreed for the evaluation. Key findings are reported against these key objectives below.






Consistency of the implementation with the original plans as identified in the Evaluation Framework

The Package has largely been implemented in a manner consistent with the Commonwealth Implementation Plan. There are some examples where the design of measures was altered in response to emerging information or enhanced understanding of factors critical to individual measures. For example, the core component of the Local Indigenous Community Campaigns to Promote Better Health (A3) measure was originally planned as a national campaign. Research conducted in 2009 by Ipsos-Eureka (now Ipsos Social Research Institute, referred to hereafter as Ipsos SRI) resulted in a shift in focus to local campaigns underpinned by a coordinated national communication and support strategy. See section 4.6 for other examples. Importantly, in each case where the implementation departed from the original plan, expert advice or emerging evidence has provided a strong rationale for a change in design.

Synergies among the measures

There are important interdependencies and linkages explicit in the design of the Package to provide levers for individual measures to enhance other measures. For example, the Workforce Support, Education and Training (C1) measure provides orientation and training to workers employed under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measures. The PBS Co-payment (B1) measure is linked at the service delivery level to the PIP Indigenous Health Incentive (provided through the Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a) measure) because patients generally register for both through the same form. The evaluation has found that the extent to which linkages between measures have been fully capitalised varies. Stakeholders have reported that, at the strategic level, the administration of the ICDP measures by different divisions of the department appears to have presented some challenges to effective coordination. However, the evaluation has also identified examples of effective coordination and synergies between measures at the point of implementation. Some stakeholders also reported that resource limitations and tight implementation timeframes have constrained their capacity to collaborate and to create linkages. However, the evaluation also identified some strong examples of synergies realised at the strategic and local levels, suggesting that other factors may be acting as barriers in some cases.

Appropriateness of individual measures and the Package

Appropriateness is considered from two perspectives as follows: Appropriateness of the measures and the Package to meet target population

and stakeholder needs, as determined by the strength of the evidence regarding the need for action and the suitability of the action taken. Overall, the need for action to address chronic disease for Aboriginal and






Torres Strait Islander people is clearly demonstrated by the existing evidence. There is evidence that generally supports the specific approaches adopted by individual measures to address the various components of need. In some cases, particularly where a measure is implementing a new approach to address a health issue, the supportive evidence for the approach is not as strong. It should be noted that developmental research was undertaken to inform the design of several measures and the evaluation has found that when this occurred the measure design was reassessed to align with the emerging evidence. This is fully explored within each measure chapter of this report.

Appropriateness, defined as awareness, appreciation of and satisfaction with the measures and Package, as described to the evaluation by stakeholders. The limited consultations undertaken to inform this Report indicate that overall, stakeholders are consistently supportive of the investment and the focus of the Package on chronic disease. Stakeholders have a strong desire to be engaged in and contribute to the successful implementation of the ICDP. Some external stakeholders commented that national priorities did not always align with local need or were not always designed with sufficient flexibility to suit local circumstances. These stakeholders consider that there is the opportunity to address these issues to ensure that ICDP has maximum effect locally.

Effectiveness of individual measures and the Package as a whole in delivering the results and outcomes

The effectiveness of individual measures and the Package as a whole in delivering the results and outcomes has not been addressed in this report. This will be covered in the Monitoring Reports relevant to years two and three of implementation. However, the key achievements outlined above are indicative of progression towards achieving early outcomes.






2. Introduction This report is the Baseline Report for the Indigenous Chronic Disease Package (ICDP or the Package) National Monitoring and Evaluation Project (hereafter referred to as the evaluation). This chapter provides an overview of the ICDP and the evaluation, the purpose and scope of this Baseline Report and an outline of the structure of this Report. 2.1 Overview of the Indigenous Chronic Disease Package (ICDP)The ICDP is the Australian Government’s contribution to the commitment made by the Council of Australian Governments (COAG) to close the gap between Aboriginal and Torres Strait Islander people and other Australians in health outcomes.

Closing the Gap in Aboriginal and Torres Strait Islander Health Outcomes

Discrepancies in life expectancy, health, education and employment outcomes between Aboriginal and Torres Strait Islander people and other Australians are well documented.5 For example, in relation to health outcomes, Aboriginal and Torres Strait Islander Australians experience a burden of disease that is two-and-a-half times that of other Australians. A large part of the burden of disease is due to chronic diseases such as cardiovascular disease, diabetes, cancer, chronic respiratory disease and chronic kidney disease.6

In late 2007, all Australian governments committed to develop and implement coordinated strategies to address the key causes and determinants of Aboriginal and Torres Strait Islander disadvantage.7 COAG identified six targets to ‘Close the Gap’ between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander Australian life outcomes, through the National Indigenous Reform Agreement.8 On 29 November 2008, COAG agreed to a $1.6 billion National Partnership Agreement (NPA) to specifically address the first of the COAG Closing the Gap targets – to close the life expectancy gap between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander Australians within a generation.9 With funding of $805.5 million over four years (2009-10 to 2012-13), the ICDP is the Australian Government’s contribution to this NPA. State and territory

5For example, see the Council of Australian Governments Steering Committee on the Review of Government Service Provision regular reports, Overcoming Indigenous Disadvantage: Key Indicators, viewed 13 September.6 Department of Health and Ageing 2012, Closing the Gap – Tackling Indigenous Chronic Disease (website) , viewed 13 September 2012.7 Department of Health and Ageing 2012, Closing the Gap – Tackling Indigenous Chronic Disease (website), viewed 13 September 2012.8 Council of Australian Governments 2011, National Indigenous Reform Agreement (Closing the Gap), viewed 16 August 2012.9 Council of Australian Governments 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, viewed 13 September 2012.




http://www.federalfinancialrelations.gov.au/content/npa/health_indigenous/ctg-health-outcomes/national_partnership.pdf

http://www.federalfinancialrelations.gov.au/content/npa/health_indigenous/ctg-health-outcomes/national_partnership.pdf

http://www.federalfinancialrelations.gov.au/content/npa/health_indigenous/indigenous-reform/national-agreement_sept_12.pdf


http://www.health.gov.au/internet/ctg/publishing.nsf/Content/home-1




http://www.pc.gov.au/gsp/indigenous

http://www.pc.gov.au/gsp/indigenous



governments have also committed to contribute to these priority areas of the NPA, through separate initiatives. These are detailed in individual jurisdictional NPA Implementation Plans.10

Aims and outcome areas of the ICDP

The ICDP aims to reduce the incidence of preventable chronic disease and improve outcomes for Aboriginal and Torres Strait Islander people with chronic disease through 14 measures across three main elements:11

Tackling chronic disease risk factors – such as smoking, poor nutrition and lack of exercise – through community education initiatives, new chronic disease prevention and health promotion workers, and implementation of healthy lifestyle and smoking cessation programs.

Improving chronic disease management and follow up care – through provision of incentives, training and support to health professionals to deliver best practice chronic disease care; improving access to medicines, specialists and primary health care services; and supporting Aboriginal and Torres Strait Islander people to self manage their chronic conditions.

Workforce expansion and support –through funding a significant number of additional positions in Indigenous health services (IHSs) and mainstream primary health care clinics; marketing activity to attract more people to work in the IHS sector; recruitment of Aboriginal and Torres Strait Islander health workers; and provision of training and support to the health workforce, including culturally appropriate clinical guidelines.

The evidence base setting out the rationale for the ICDP’s focus on chronic disease is set out in section 4.2 below.

ICDP measures and activities

The 14 inter-related measures include a range of health promotion and social marketing activities, reforms to existing programs, and new initiatives and funding to increase the size and capacity of health care services for Aboriginal and Torres Strait Islander people. These are organised under the three priority areas (which correspond to the three categories above) of tackling chronic disease factors, primary health care services that deliver and fixing the gaps and improving the patient journey.Table 1 lists the 14 ICDP measures by priority area, letter/number measure code and measure title. Information on the design of the Package overall is given in section 4.1 below. Details on each measure, including its design, evidence base, expected outcomes, reach, timeframes and baseline status, are provided in separate chapters of this Baseline Report.

10 See Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plans, viewed September 2012.11 See Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plans, viewed September 2012.




http://www.federalfinancialrelations.gov.au/content/npa/health_indigenous.aspx






Table 1: Overview of ICDP measures. Source: National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan Jurisdiction: Commonwealth.12

Priority Area Measure code and measure title

Tackle chronic disease factors

A1- National Action to Reduce Aboriginal and Torres Strait Islander Smoking Rates (also referred to within this report as the Tackling Smoking measure)


A2 - Helping Aboriginal and Torres Strait Islander People(s) Reduce Their Risk of Chronic Disease (also referred to within this report as the HLW measure)


A3 - Local Aboriginal and Torres Strait Islander

Community Campaigns to Promote Better Health (also referred to within this report as the LCC measure)

Primary health care services that deliver

B1 - Subsidising Pharmaceutical Benefits Scheme (PBS) Medicine Co-payments (also referred to within this report as the PBS Co-payment measure)


B2 - Higher Utilisation Costs for Medicare Benefits Schedule (MBS) and PBS


B3 - Supporting Primary Care Providers to Coordinate Chronic Disease ManagementB3a - Practice Incentives Program (PIP) Indigenous Health Incentive(also referred to within this report as the PIP Indigenous Health Incentive /measure)B3b - Care Coordination and Supplementary Services (CCSS) Program (also referred to within this report as the CCSS measure)


B4 - Improving Aboriginal and Torres Strait Islander

Participation in Health Care through Chronic Disease Self Management (also referred to within this report as the Chronic Disease Self Management measure)

12 See Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plans, viewed September 2012.








Priority Area Measure code and measure title


B5 - Increasing Access to Specialist and Multidisciplinary Team CareB5a - Urban Specialist Outreach Assistance Program (also referred to within this report as USOAP)B5b - Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease (also referred to within this report as MSOAP-ICD)


B6 - Monitoring and Evaluation

Fixing the gaps and improving the patient journey

C1 - Workforce Support, Education and Training


C2 - Expanding the Outreach and Service Capacity of Indigenous Health Organisations


C3 - Engaging Divisions of General Practice to Improve Aboriginal and Torres Strait Islander Access to Mainstream Primary Care (also referred to within this report as the Improving Access to Mainstream Primary Care measure)


C4 - Attracting More People to Work in Aboriginal and Torres Strait Islander Health


C5 - Clinical Practice and Decision Support Guidelines






2.2 Overview of the ICDP evaluation The ICDP includes funding to monitor and evaluate the Package. The Indigenous Chronic Disease Package Monitoring and Evaluation Framework (the Evaluation Framework) was originally developed by Urbis in 2010 and can be viewed at the Monitoring and Evaluation website.13 The Framework guides two evaluation projects - the National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.14

Conduct of the ICDP National Monitoring and Evaluation

In July 2011, the Australian Government Department of Health and Ageing (the department) engaged a consortium of independent consultants to conduct the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (referred to hereafter as the evaluation) guided by the Evaluation Framework. The consortium includes: KPMG, as the lead evaluator; Winangali, an Indigenous communications firm, which supports the conduct of

community consultations for the evaluation; Baker IDI, which leads the health economics components of the evaluation;

and Ipsos-Eureka (now Ipsos Social Research Institute, referred to hereafter as

Ipsos SRI), to guide the evaluation of social marketing and community campaign components of the ICDP.

The purpose of the evaluation is to undertake ongoing monitoring and evaluation of the implementation and impact of the ICDP as a whole, and of the individual measures which make up the Package. The evaluation will be both formative and summative in nature – considering the implementation and operation of the ICDP, the achievement of outcomes, and the contribution made by the Package and its individual measures to the broader aims and objectives of Closing the Gap. The evaluation involves consideration of: consistency of the implementation of individual measures and the Package

with the original plans, as identified in the Evaluation Framework; synergies among the measures – the extent to which the Package and

individual measures are consistent and coordinated with, and complementary to, each other and the Package’s aims;

13 Urbis Pty Limited 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework. September 2010, Volumes 1, 2 and 3 , Department of Health and Ageing, Canberra.14 The Sentinel Sites Evaluation (SSE) project, being conducted by Menzies School of Health Research, aims to provide early observations on the progress of the implementation of the ICDP. Sentinel Sites are defined geographic areas across Australia which cover metropolitan, regional and remote areas. Via regular six monthly reports on progress of implementation in these selected sites, the SSE focuses on monitoring implementation at the local level. See: Monitoring and Evaluation (website).




http://www.health.gov.au/internet/ctg/publishing.nsf/Content/ctg-gp-kit-annual-progress-report-toc~ctg-gp-kit-annual-progress-report-monitoring-and-evaluation

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effectiveness of individual measures and the Package as a whole in delivering the results/outcomes (early, medium and long term) identified in the Evaluation Framework at various stages of implementation; and

appropriateness of individual measures and the Package as a whole to the target population and stakeholder needs.

There are three key phases to the evaluation: Baseline – which establishes a baseline or comparator for future change to be

compared against, through identifying what existed prior to the introduction of the ICDP and what happened in the first year of implementation of the ICDP. This Baseline Report is the key output from this phase.

Monitoring – undertaken at two points in time (2010-11 and 2011-12), which will assess the progress that has occurred in implementation of the ICDP measures in each year; the success of the individual ICDP measures and the Package in achieving the ‘early results’ specified in the Evaluation Framework; the identification of barriers and facilitators to success, and an assessment of the contextual factors impacting on implementation; and opportunities for improvement. Two Monitoring Reports will be the key outputs from this phase.

Final Report – which will reflect data collection activity reserved for the latter stages of the evaluation when measures are more mature in their implementation, and integrate the evidence collected across measures and across the course of the evaluation in order to comment on the success of the ICDP overall in achieving the intended outcomes. This includes discussing trends in the data over time, as well as contribution analysis in achievement of policy aims. The Final Evaluation Report will be the key output from this phase.

Throughout the duration of the evaluation, evaluation findings will be available to inform ongoing implementation of the ICDP.

Methods used in the evaluation

A mixed methods approach is being taken to the ICDP evaluation, including both qualitative and quantitative methods for data collection and analysis. The key methods of the evaluation include: qualitative methods such as literature and document reviews, individual

stakeholder consultations, collective stakeholder consultations (referred to as ICDP Forums), community site visits and opportunistic evaluation activities (e.g., observation at key events);

quantitative methods such as analysis of secondary data sources and surveys; and

mixed methods such as Patient Journey and Service Mapping, case studies and contribution and attribution analysis.






2.3 Purpose and scope of this Baseline Report As noted above, this Baseline Report is the key output from the first phase of the evaluation. The purpose of this Report is to establish a baseline for the ICDP against which the implementation and impact of the Package can be compared. In an evaluation, a baseline is typically a snapshot in time of the state of play before an initiative, policy, program or activity, was introduced. In the case of the ICDP, the overall baseline is given by the summary statistics against key indicators which are relevant to each measure, presented in Appendix F. These statistics show outcomes for Aboriginal and Torres Strait Islander people such as life expectancy, leading causes of mortality, rates of chronic disease and smoking, prevalence of chronic disease risk factors, common reasons for hospitalisation, social and emotional wellbeing, self reported access to health services, and number of Aboriginal and Torres Strait Islander health workforce staff and students. As time elapses and the ICDP progresses, the evaluation will undertake further analysis of data relating to these outcomes (where possible), to observe whether change is occurring relative to this baseline and determine to what extent any change can be attributed to the ICDP. This document also provides a detailed description of the design of each measure and reports on what was achieved in the first year of the ICDP (1 July 2009 – 30 June 2010). Future reports of the evaluation will present evidence and analysis on the second (2010-11), third (2011-12) and the fourth (2012-13) years of the ICDP implementation. These reports will gradually shift in emphasis from focusing on progress with and lessons learned in implementation, to early results and outcomes for Aboriginal and Torres Strait Islander people and the healthcare system.

Methodology for establishing a baseline

The following broad activities have informed the development of a baseline for this report: review of ICDP program documentation; targeted review of journal literature, research and evaluation reports relevant

to the evidence base for the ICDP measures, and publicly available information about other Australian and state and territory government programs and initiatives with similar aims and objectives to the ICDP;

analysis of the Baseline and the First Evaluation Report of the separate Sentinel Sites project15;

analysis of secondary data, including PIP Indigenous Health Incentive data, MBS and PBS data, data available based on quarterly reports to COAG against the Aboriginal and Torres Strait Islander Health Performance Framework (HPF); and other national surveys and databases, and ICDP program data; and

15 Menzies School of Research 2010, Sentinel Sites Evaluation Report December 2010, Department of Health and Ageing, Canberra.






analysis of qualitative data and information collected through consultations including semi-structured interviews with key stakeholders and community site visits.

Further detail on each of these activities is given in Appendix A.2.4 Structure of this document This report contains an introduction and overview of the ICDP and the evaluation (this chapter, chapter 2), a discussion of the contextual baseline (chapter 3), the ICDP baseline (chapter 4) and individual measure baselines including data analysis relevant to individual measures (chapters 2 through 19). Appendices include: Appendix A – Methodology for the Baseline Report Appendix B – Stakeholders consulted Appendix C – Synergies between ICDP measures Appendix D – Policy maps of other Commonwealth, state and territory

activities linked or relevant to the ICDP Appendix E – Discussion of secondary data sources Appendix F – Summary statistics for whole-of-ICDP indicators






3. Contextual baseline This chapter provides a discussion of external contextual factors that may impact on the ICDP. 3.1 Important contextual factorsIt is well recognised that a complex and interrelated set of factors act as determinants of health outcomes, and contribute to the poorer health outcomes of Aboriginal and Torres Strait Islander people. As acknowledged by Urbis in their 2010 ICDP Monitoring and Evaluation Framework, Volume 1, “a large number of social determinants of Indigenous health rest outside the influence of the formal health sector.”16 Some of the factors influencing the health outcomes of Aboriginal and Torres Strait Islander people are discussed below.

Historical experiences and embedded disadvantage

Disadvantage experienced by Aboriginal and Torres Strait Islander people is often intergenerational in nature and deeply entrenched.17 Disadvantage is experienced across a range of areas such as educational attainment and economic participation, and as the discussion on social and environmental determinants below highlights, disadvantage which is experienced broadly can have a direct impact on health outcomes.18 There are also direct links between historical experiences and current health outcomes, for example the high incidence of Aboriginal and Torres Strait Islander smoking has been linked to payment of Aboriginal and Torres Strait Islander people with tobacco for work during mission times.19

Social and environmental factors

Social and environmental factors have a significant impact on health. For example: poor housing, lack of sanitation and overcrowding are directly linked to poor hygiene which in turn can lead to higher rates of infectious diseases20 21;

16 Urbis 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Project, Volume 1, Urbis, Sydney.17 Cobb-Clark D 2011, Disadvantage across the generations: What do we know about social and economic mobility in Australia?, Australian Institute of Family Studies seminar serried presentation, 14 April 2011, AIFS seminar room, Melbourne.18 Anderson I 2007, Social Determinants of Indigenous Health, eds. B Carson et al, Allen & Unwin, Sydney19 Brady M 2002, ‘Historical and cultural roots of tobacco use among Aboriginal and Torres Strait Islander people’, Australian and New Zealand Journal of Public Health, vol. 26, no. 2, pp. 120-124.20 Atkinson P, Buckworth M & Dean F 2007, An Overview of the Current Knowledge of the Social Determinants of Indigenous Health, Commission on Social Determinants of Health.21 Australian Institute of Health and Welfare2008, The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2011, AIHW, Canberra.






and poverty and low educational attainment are linked to higher incidence of risk factors such as smoking, and lower health literacy.22

Remoteness can also impact health outcomes, with many remote communities having few or no services available to address the needs of community members.23 Social factors, both at the individual and community level, such as alcohol and substance misuse, family breakdown and ‘lateral violence’24 can exacerbate disadvantage associated with poverty and remoteness.

Service access

The presence of these social and environmental determinants can have a significant impact on access to services by Aboriginal and Torres Strait Islander people. It is well evidenced that Aboriginal and Torres Strait Islander people have poorer access to services than other Australians and that service access is influenced by a range of factors including the cultural appropriateness of services; lack of access to transport; service proximity; and health literacy.25 26 Lack of access to services can be particularly common in rural and remote areas27, but is also experienced in urban communities.28 29 Lack of access to services, particularly primary health care services, can lead to increased use of acute services and significantly impact health outcomes in the longer term. 3.2 Policy contextThe ICDP Monitoring and Evaluation Framework (the Evaluation Framework) developed by Urbis in 2010 states that “[t]he ICDP is one of a number of

22 Australian Health Ministers’ Advisory Council 2008, Aboriginal and Torres Strait Islander Health Performance Framework Report 2008, AHMAC, Canberra.23 Centre for Aboriginal Economic Policy Research 2000, Governance and service delivery for remote Aboriginal communities in the Northern Territory: challenges and opportunities, CAEPR, Canberra.24 Internalised conflict within Aboriginal and Torres Strait Islander communities, including violence, bullying, gossiping, jealousy and family feuding, thought to be a result of colonisation, oppression and discrimination. See the Australian Human Rights Commission. 2011. Social Justice Report 2011. Sydney. 25 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp 517-512.26 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.27 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, no. 4, pp. 196-201.28 National Aboriginal Community Controlled Health Organisation 1997, Submission by NACCHO to the House of Representatives Standing Committee on Family and Community Affairs, viewed September 2012.29 Scrimgeour M & Scrimgeour D 2008, ‘Health Care Access for Aboriginal and Torres Strait Islander People Living in Urban Areas, and Related Research Issues: A Review of the Literature’, CAPER Discussion Paper Series, no. 5, CAPER, Casuarina.




http://www.naccho.org.au/policies/hor-subx2.html

http://www.naccho.org.au/policies/hor-subx2.html

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initiatives that are seeking to prevent, detect and better manage chronic disease conditions amongst Aboriginal and Torres Strait Islander people. Running parallel to the ICDP over the next three years are various: national Indigenous health programs targeting chronic disease and healthy

lifestyle choices; state and territory specific Aboriginal and Torres Strait Islander health

programs or initiatives along the same lines; national (mainstream) strategies targeting chronic disease conditions; and state and territory chronic disease strategies.”In addition to chronic disease and healthy lifestyle programs, there are numerous workforce programs and strategies in place at both state/territory and national levels which aim to increase the capacity and capability of the Aboriginal and Torres Strait Islander health workforce. These programs, strategies and initiatives have implications for the evaluation of the ICDP, as many involve similar activities and objectives to the ICDP, or are formally linked to the ICDP, and thus may also contribute to the achievement of identified ICDP outcomes.As such, the policy maps below identify policies, programs, strategies and initiatives that directly and formally link with the ICDP, or are relevant to the ICDP due to shared or similar activities, objectives and desired outcomes. The national and jurisdictional policy maps will inform the contribution analysis to be conducted in the later stages of the evaluation.3.3 National policy mapThe national policy map considers: national health reform agreements; and other relevant policies, programs and initiatives operating at the national

level including those that are:- Aboriginal and Torres Strait Islander-specific and targeting health

workforce, chronic disease and healthy lifestyle choices; and- mainstream and targeting chronic disease and healthy lifestyle choices.

The ICDP is directly and formally linked to a range of other programs and initiatives under two key national reform initiatives – the COAG National Indigenous Reform Agreement (NIRA) and the National Health Reform Agreement (NHRA). These linkages are discussed in detail below. Under the NIRA, a range of programs and initiatives aiming to address Aboriginal and Torres Strait Islander disadvantage are being implemented under six key National Partnership Agreements between the Australian and state/territory governments. The ICDP is one of a number of initiatives working towards, at a high level, the common aims and desired outcomes of the NIRA. As a result






many of the NIRA programs and initiatives link with the ICDP and are likely to impact in similar areas. These links are illustrated in Appendix D.More broadly, as part of the NIRA, the department, state and territory departments of health and the Australian Institute of Health and Welfare (AIHW) are developing national key performance indicators for Indigenous health services. These indicators will “monitor, inform, and provide a direct line of sight between the activities of federal and state- and territory-funded services that provide primary health care to Aboriginal and Torres Strait Islander people, and the COAG Closing the Gap targets, in particular the targets for life expectancy and child mortality.“30 As such these indicators are a formal link between the ICDP and other initiatives under the NIRA. Appendix C provides an overview of these NPAs and their links and/or relevance to the ICDP.In addition to the NIRA and the NHRA, there are various programs, strategies and initiatives operating at a national level that link with the ICDP. These, and their alignment with the ICDP measures, are also detailed in Appendix C.3.4 Jurisdictional policy mapThe jurisdictional policy map considers: state/territory initiatives under the NPA on Closing the Gap in Indigenous

Health Outcomes (being implemented under the NIRA); and other relevant policies, programs and initiatives operating at the

state/territory level including:- mainstream and Aboriginal and Torres Strait Islander-specific chronic

disease and healthy lifestyle programs, strategies and initiatives; and- Aboriginal and Torres Strait Islander health workforce programs, strategies

and initiatives.

State and Territory Closing the Gap in Indigenous Health Outcomes initiatives

As noted in section 2.1 above, the ICDP is the Australian Government’s contribution to the COAG NPA on Closing the Gap in Indigenous Health Outcomes. In parallel, each state and territory government has its own Closing the Gap health initiative, and has developed an implementation plan setting out the activities it will undertake to contribute to the National Partnership Agreement.31 These initiatives vary in terms of their specific activities and desired outcomes. However, many of the activities being implemented in states and territories have

30 Australian Institute of Health and Welfare 2011, Indigenous primary health care key performance indicators (2012), viewed April 2012.31 Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Pla n (links to implementation plans) , viewed September 2012.






http://meteor.aihw.gov.au/content/index.phtml/itemId/430638

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either a direct or indirect link with the ICDP. These links include similar objectives and activities to those of the ICDP. Table 2 below provides an overview of the shared areas of impact between the state and territory Closing the Gap initiatives, and the ICDP measures.32 A detailed identification of state and territory Closing the Gap programs and activities that are directly relevant to chronic disease or the ICDP is provided in Appendix D. These programs and activities are highly relevant to the ICDP, potentially presenting challenges in differentiating between their impacts and the impact of the ICDP. However, it is important to note that states and territories are aiming to complement the Commonwealth’s activities under Closing the Gap, as stated within many of the state/territory implementation plans.

32 Tasmania signed the NPA later than other states and territories, therefore information is not provided for the 2009-10 year for Tasmania






Table 2: Broad analysis of linkages and crossovers between state and territory implementation plans under the Closing the Gap in Indigenous Health Outcomes, and the ICDP.33

Level of impact

Area of impact NSW QLD WA NT VIC SA TAS ICDP

System impacts

Expanded workforce capacity – the Aboriginal and Torres Strait Islander health workforce is increased

y n/a y y n/a y n/a y

System impacts

Enhanced workforce capability – the Aboriginal and Torres Strait Islander health workforce is more capable of providing appropriate, high quality care

y y n/a y y y n/a y

System impacts

Improved cultural appropriateness of mainstream processes, services

y y y y y y n/a y

System impacts

Increased availability of programs and services – (number of programs, geographical accessibility, opening hours, cultural accessibility etc), particularly to people in remote areas

y y y y y y n/a y

System impacts

Enhanced system linkages – care coordination and partnerships, promoting continuity of care and an improved patient journey

y y y y y y n/a y

33 Ministerial Council for Federal Financial Relations n.d., National Partnerships – Indigenous (links to Implementation Plans ), viewed August 2011,

34KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG

International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards Legislation.




Level of impact

Area of impact NSW QLD WA NT VIC SA TAS ICDP

Community impacts

Increased community engagement and participation – in service provision, in determining health activities within their community etc

y y y y y y n/a y

Community impacts

Enhanced community health literacy – at the community level, there is a better understanding of health issues, and greater ability to address these

y y y y y y n/a y

Individual impacts

Improved knowledge and awareness of health issues - such as what are risk factors, why do health problems occur

y y y y y y n/a y

Individual impacts

Improved access and connection to services – at the individual level people can access services because they know about the services, they know how to access them, they feel comfortable accessing them etc

y y y y y y n/a y

Individual impacts

Increased health self management capability – individuals understand and are able to implement strategies to prevent or manage their health problems

y y y y y y n/a y

35KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG

International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards Legislation.



4. Whole of ICDP baseline This chapter describes the baseline for the ICDP as a whole. The baseline of individual measures is given in separate chapters on each measure (chapters 4-18 below). This chapter provides an overview of the design of the ICDP, the rationale and supporting evidence, the outcomes it is expected to achieve (causal pathway), the designed reach and timeframes for the Package, and year one progress. 4.1 Design of the Indigenous Chronic Disease Package (ICDP) The design of the ICDP responds to the evidence which shows that chronic diseases and associated risk factors amongst Aboriginal and Torres Strait Islander Australians are responsible for approximately two-thirds of this life expectancy gap. Section 2.1 provides an overview of the design of the ICDP.

Governance, leadership and strategy

The ICDP is overseen at a strategic level by the Council of Australian Governments (COAG) Indigenous Health Coordination Committee and the Department’s Program Management Group. The implementation of the ICDP is largely administered within the Central Office of the department, with some of the contractual arrangements managed through departmental state and territory offices (STOs). Existing or specifically-established technical reference or advisory groups comprised of key stakeholders from outside government, provided advice on the design of many individual ICDP measures. Pre-existing Indigenous Health Partnership Forums (IHPFs) in each state and territory also provided guidance to the department on the early implementation of the ICDP. The IHPFs include representation from the STOs, state and territory governments, the National Aboriginal Community Controlled Health Organisation (NACCHO) state/territory affiliate organisation and in some cases the State Based Organisation (SBO) of the Divisions of General Practice.

Various national peak bodies were involved in implementation of the ICDP in one of two ways. Some peak bodies participated in technical reference groups or advisory groups, and others are recipients of ICDP funding to deliver an aspect of ICDP. In some cases, peak bodies fulfilled both roles, such as NACCHO and the Australian General Practice Network (AGPN).

Stakeholders

below identifies the different stakeholder groups relevant to the ICDP, and their specific roles in respect of the Package.






Table 3: Relevant stakeholder groups and their role in the ICDP as a whole.34

Stakeholder Role in ICDP as a wholeAboriginal and Torres Strait Islander people

Communities: engage with services and activities provided through ICDP measures, such as delivering health promotion messagesPeople with or at risk of chronic disease: engage with services and activities; receive benefits from ICDP measuresAboriginal and Torres Strait Islander ICDP workforce: deliver relevant ICDP measures

Department - Central Office

Design the ICDP and measures; manage fund holder contracts; oversee implementation; manage monitoring, reporting and evaluation

Department -State/Territory Offices

Manage fund holder contracts for some measures

Department of Human Services (Medicare)

Administer one ICDP measure (PIP Indigenous Health Incentive)Provide data to inform monitoring and evaluation of the ICDP

State and Territory Health Departments

No direct role. Separately contribute to the NPA on Closing the Gap in Indigenous Health Outcomes, as identified in distinct state/territory implementation plans (refer to section 3.4)

Measure-specific advisory bodies

Provide expert advice on ICDP measure design and implementation

Indigenous Health Partnership Forums

Advise the Department regarding local implementation of the ICDP measures

National peak bodies

Participate in Department’s consultation activitiesIn some cases, participate as fund holders in some ICDP measures (e.g., AGPN, NACCHO, RACGP)

State/territory affiliates of national peak bodies

Participate in Department’s consultation activitiesIn some cases, participate as fund holders in some measures (e.g., SBOs and NACCHO affiliates)

ICDP fund holder organisations

Implement ICDP measures in accordance with funding agreement requirements; provide reports to the Department

34 Based on information provided by the Department of Health and Ageing.37





Stakeholder Role in ICDP as a wholeICDP workforce In accordance with the funding agreement, implement

measure activities, receive orientation and training, participate in national, state/territory and regional networking and knowledge-sharing activities, and contribute to monitoring and evaluation

Consulting and research organisations

Provide consulting services to the Department to inform measure design, implementation, monitoring, reporting and evaluation.

Adherence to service delivery principles

The ICDP is expected to adhere to the six service delivery principles of the COAG Closing the Gap National Indigenous Reform Agreement (NIRA).35 The description below provides the definition for each of the NIRA principles and identifies how they have been applied within the ICDP as a whole.Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The ICDP is designed to contribute to closing the gap in life expectancy by

reducing the incidence of preventable chronic disease and by improving treatment and management of chronic diseases, a major contributor to Aboriginal and Torres Strait Islander Australian morbidity and mortality.

All of the ICDP measures focus on one or more of the Closing the Gap priorities and targets and have been designed to engage local stakeholders and respond to local needs.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. Aboriginal and Torres Strait Islander people and communities have been

involved in ICDP implementation:- nationally through the involvement of various peak bodies and advisory

groups, including the National Aboriginal and Torres Strait Islander Health Equity Council;

- in states and territories through the Indigenous Health Partnership Forums; and

- locally where IHSs and in some cases community organisations are funded to provide services or initiate local action as part of ICDP.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. All measures are funded to sustain their activities for the first four years of

the Package. Many of the measures are designed to continue on beyond the 35 Council of Australian Governments 2011, National Indigenous Reform Agreement (Closing the Gap), Schedule D, viewed 16 August 2012.








initial (4 year) ICDP funding period which is consistent with the recognition in the NPA that achieving the targets will take substantial time (i.e., beyond the current ICDP timeframe), although this is not confirmed.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. Many ICDP measures are specifically designed to improve Aboriginal and

Torres Strait Islander peoples’ access to health-related programs and services; improving cultural accessibility is a specific aim in the mainstream service sector.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. Under the COAG NPA on Closing the Gap in Indigenous Health Outcomes, the

Commonwealth and each jurisdiction has developed separate implementation plans for distinct initiatives and there is no explicit collaboration between governments. The ICDP is the Commonwealth’s initiative.

Indigenous Health Partnership Forums (which include state and territory government representation) have been called on to inform the implementation of some ICDP measures. Other collaboration and coordination between the department and other stakeholders is undertaken through dedicated advisory bodies and the implementation activities of the department.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. The department has contractual arrangements in place with all funding

recipients which require progress reporting and expenditure acquittals. One of the ICDP measures, Monitoring and Evaluation (B6), comprises a multi-

faceted monitoring and evaluation strategy that includes:- this national evaluation; and- the sentinel sites project.

4.2 Rationale and supporting evidenceAs noted in section 2.1 above, COAG has set a target to close the gap between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander life expectancy within a generation (25 years). The Australian Institute of Health and Welfare has found that 80 per cent of the mortality gap can be attributed to chronic diseases – most significantly heart diseases (22 per cent), diabetes (12 per cent) and liver diseases (11 per cent) – and that much of this chronic disease is potentially preventable.36 The ICDP attempts to respond to these factors, to contribute to all Australian governments’ commitment to close the life expectancy gap.

36 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, cat. no. 4704.0, AIHW, Canberra.






Relevant data shows that there have been no significant changes in the causes of Aboriginal and Torres Strait Islander deaths over the period preceding the ICDP, 2006-09. Aboriginal and Torres Strait Islander people continue to die of the same causes at approximately the same rates. These causes are predominantly chronic disease or linked to chronic disease: circulatory diseases, cancers, respiratory diseases, and endocrine, metabolic and nutritional disorders such as diabetes.37

Chronic disease is not only a significant factor in the life expectancy gap between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander Australians; it is also a factor in a ‘health gap’ between these populations. Overall, the burden of disease for Aboriginal and Torres Strait Islander people is estimated to be two times greater than the burden of disease in the broader Australian population. The incidence of chronic disease is also much higher. When compared to other Australians, Aboriginal and Torres Strait Islander people experience: 1.7 times the rate of hospitalisation for cardiovascular disease 38; three times the rate of diabetes39, and development of diabetes at earlier

ages40; higher rates of respiratory disease, including double the rate amongst

children 41; higher rates of renal disease, and a significantly increasing incidence of this

disease over recent years42; higher rates of cervical and lung cancer 43; between 1.4 and 1.6 times the rate of high blood pressure44;

37 COAG Reform Council 2012, Indigenous Reform 2010-11: Comparing performance across Australia, Report to the Council of Australian Governments, viewed 14 August 2012.38 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.39 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2004-05, 1.08, AHMAC, Canberra.40 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.41 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.42 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.43 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.44 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2004-05, 1.07, AHMAC, Canberra.




http://www.coagreformcouncil.gov.au/reports/indigenous.cfm

http://www.coagreformcouncil.gov.au/reports/indigenous.cfm



twice the rate of hospitalisation for mental health problems45; and higher rates of hospitalisation generally.46

Although the chronic diseases that Aboriginal and Torres Strait Islander people commonly experience are similar to those experienced in the broader population47, it is acknowledged that different approaches to chronic disease treatment are required.48

Chronic diseases have multiple causes in addition to health-specific factors, including social determinants such as educational attainment; environmental determinants such as access to fresh food and nutrition; psychosocial factors such as resilience or connection with the community; behavioural determinants such as physical inactivity; biological risk factors; genetic factors; and accessibility and affordability of health care services.49

Tackling chronic disease risk factors

The ICDP is putting in place a range of health promotion and healthy lifestyle programs and interventions to address the risk factors associated with chronic disease.For Aboriginal and Torres Strait Islander people, health risk factors are estimated to account for at least a third of the burden of chronic disease.50 Smoking is considered one of the main risk factors for mortality of Aboriginal and Torres Strait Islander people, with a high incidence of smoking both across the population, and particularly prevalent amongst some population groups, for example young people.51 Other significant impacting factors are: Sedentary lifestyles – the proportion of sedentary Aboriginal and Torres Strait

Islander people is increasing52; Fruit and vegetable intake – Aboriginal and Torres Strait Islander people over

12 years of age are seven times as likely to report no daily vegetable intake

45 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.46 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2006-08, 1.02, AHMAC, Canberra.47 National Public Health Partnership 2001, Preventing Chronic Disease: A Strategic Framework, National Public Health Partnership, Canberra.48 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.49 Whitby B, & Herriot M 2006, ‘The Prevention of Chronic Disease – The Policy Context’, Public Health Bulletin, Edition 3, 2006, pp. 2-6.50 Australian Institute of Health and Welfare 2010, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Cat. No. 4704.0, AIHW, Canberra.51 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2008, 2.18, AHMAC, Canberra.52 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2004-05, 2.22, AHMAC, Canberra.






and twice as likely to report no daily fruit intake than non-Aboriginal and Torres Strait Islander Australians53; and

Obesity – Aboriginal and Torres Strait Islander adults are twice as likely to be obese than other Australian adults, and this is particularly an issue amongst males.54

By addressing such lifestyle-related risk factors, chronic disease can both be prevented and its progression slowed for people with existing chronic disease. Effective health promotion is considered critical and one way in which health improvement can be achieved, particularly in the area of chronic disease. Health promotion can support increased self empowerment and self efficacy, eventually leading to behaviour change in some cases.55 Prevention – as a key element of comprehensive primary health care delivery – is also considered critical in addressing chronic disease and other poor health experienced by Aboriginal and Torres Strait Islander people.

Improving chronic disease management and follow up care

The ICDP focuses on improving chronic disease management and follow up care by increasing access to health care (both initial and follow up) and providing more effective health care to Aboriginal and Torres Strait Islander people across Australia.Aboriginal and Torres Strait Islander people, including those with chronic disease, experience lower levels of access to health care than other Australians, particularly those living in remote areas.56 For example, Aboriginal and Torres Strait Islander people are less likely to be treated for cancer, which has a negative impact on survival rates.57 Lack of access to primary health care services can result in increased use of acute health care, particularly at crisis points, for example, the acute exacerbation of a chronic condition. Around 79 per cent of all hospital admissions for Aboriginal and Torres Strait Islander people can be linked to a chronic condition.58 Improved access to health services, including to providers, medicines and testing, is thus considered essential to improve both prevention and chronic disease management. A literature review undertaken as part of the developmental research for the ICDP suggests that some Aboriginal and Torres Strait Islander people are likely to

53 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2004-05, 2.23, AHMAC, Canberra.54 Australian Health Ministers’ Advisory Council 201, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2004-05, 2.26, AHMAC, Canberra.55 Mikhailovich K, Morrison P and Arabena K 2007, ‘Evaluating Australian Indigenous community health promotion initiatives: a selective review’, Rural and Remote Health, 7: 746.56 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2008, 3.12, AHMAC, Canberra.57 Council of Australian Governments 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, Commonwealth of Australia, Canberra.58 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2006-08, 3.06, AHMAC, Canberra.






believe that if the body is currently not experiencing significant illness, there is no need for concern. This may impact upon levels of service access.59 A focus on increasing access to preventative health care, such as health checks, is thus important. Health checks are one way in which health problems can be picked up early, supporting preventative health care. They can also increase the frequency of engagement with the preventative health care system by patients.60

Service availability more broadly can be an issue for many Aboriginal and Torres Strait Islander people, and is impacted by the cultural accessibility and affordability of services in urban, regional and remote areas.61, 62 Therefore, addressing affordability and availability issues is essential. Providing effective services is also key to improving chronic disease care. Some of the fundamental elements that have been shown to lead to successful Aboriginal and Torres Strait Islander chronic disease programs include: a focus on chronic disease self management and increased health literacy; referral to appropriate service and assistance to patients to navigate the

service system; follow up with clients about their results and ongoing care; and involvement of multidisciplinary teams or taskforces.63

Workforce expansion and support

The ICDP aims to expand the Aboriginal and Torres Strait Islander health workforce through recruitment of additional workers (both Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander workers) and providing support to workers through providing or increasing the availability of training/mentoring and resources. While the Aboriginal and Torres Strait Islander health workforce has grown over the last 12 years, the rate of growth has been less than that amongst the mainstream health workforce64, and there remain issues with attracting and retaining people to work in the area of Aboriginal and Torres Strait Islander

59 Ipsos-Eureka Social Research Institute & Winangali 2010, Developmental Research to inform the Local Indigenous Community Campaigns to Promote Better Health, Prepared for the Department of Health and Ageing, Ipsos-Eureka, Sydney.60 Harris, M 2008,The role of primary health care in preventing the onset of chronic disease, with a particular focus on the lifestyle risk factors of obesity, tobacco and alcohol, Centre for Primary Health Care and Equity, University New South Wales, Sydney61 Lexchin J & Grootendorst P 2004, ‘Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: a systematic review of the evidence’, Int J Health Serv, 34, pp. 101-122.62 Gruen R & Bailie R 2004, ‘Specialist clinics in remote Australian Aboriginal communities: where rock art rock art meets rocket science’, Journal of Health Services Research & Policy, vol. 9.63 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.64 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2006, 3.10, AHMAC, Canberra.






health.65 The disparity in growth rates should be considered in the context of the higher health care needs of Aboriginal and Torres Strait Islander people. Around 60 per cent of Aboriginal and Torres Strait Islander people access mainstream health services66, so enhancing the cultural competency of mainstream providers is also important in ensuring service accessibility.Expanding the Aboriginal and Torres Strait Islander health workforce is important to support the increasing demands for health care amongst Aboriginal and Torres Strait Islander people. The evidence suggests that a focus on recruiting Aboriginal and Torres Strait Islander workers is likely to lead to increased engagement with health services by the Aboriginal and Torres Strait Islander population.67 In addition, strengthening this workforce leads to improved outcomes across other areas such as employment/economic participation. To support recruitment and retention of these workers, a focus on strategies that have been demonstrated to be effective is likely to be key. Areas to consider include culturally appropriate recruitment methods68, availability of training, support and mentoring69, and financial incentives. 4.3 The central causal pathwayFigure 1 below presents the desired outcomes that the ICDP as a whole is expected to make through the combined effect of the individual measures, and how these are assumed to be interrelated.The causal model will be used by the evaluation in the contribution analysis planned for the Final Evaluation Report, in association with the rationale for the Package and the associated evidence base, and the assessment of external factors which may potentially impact on any observed effects of the ICDP as a whole.

65 Australian Institute of Health and Welfare 2010, Aboriginal and Torres Strait Islander health services report, 2008-09, OATSIH Services Reporting – key results, Cat. no. IHW 31, AIHW, Canberra.66 Based on information provided by the Department of Health and Ageing.67 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol 6: 606, pp.1-15.68 Watson C & Harrison N 2009, New South Wales Aboriginal Mental Health Worker Training Program: Implementation Review, New South Wales Health and the Cooperative Research Centre for Aboriginal Health, New South Wales.69 Hunter BH 2010, ‘Pathways for Indigenous school leavers to undertake training or gain employment’, Resource Sheet no. 2, Produced for Closing the Gap Clearinghouse, Australian Institute of Health and Welfare, Canberra & Australian Institute of Family Studies, Melbourne.






Aboriginal and Torres Strait Islander people

increase their utilisation of

mainstream primary health care services

Increase in health system capacity and capability to deliver primary health care

services to Aboriginal and Torres Strait Islander people

Improvement in Aboriginal and Torres Strait Islander people’s

chronic conditions

Reduced chronic disease risk factors

A reduction in the incidence and

prevalence of chronic disease for Aboriginal

and Torres Strait Islander people

Indigenous Chronic Disease Package

Better health outcomes and increased life

expectancy for Aboriginal and Torres Strait Islander people

Figure 1: Overarching ICDP causal pathway. Source: KPMG. 4.4 Reach and timeframesThe reach and timeframes within which outcomes can be expected to occur are largely dictated by the design and implementation of the individual measures (see the dedicated sections on reach and timeframes for each measure within chapters Error: Reference source not found through 19). The concept of ‘reach’ in this Report refers to the potential and actual penetration of the ICDP and the individual measures’ impact on the intended target group. In relation to the reach of the ICDP as a whole, the design of each measure in some way limits the potential reach of the ICDP. Those reliant on workforce elements (the majority of measures) are limited by the allocation of workers between and within jurisdictions. The potential reach of the Local Community Campaigns to Promote Better Health (A3) measure is limited by the approval of grants, and extended by the health promotion activities such as national Healthy Community Days and website. Even measures more broadly available such as the PIP Indigenous Health Incentive and the PBS co-payment are limited in reach because they are not universally available throughout Australia. The actual reach of these measures will be determined by participation, either of providers (for example PIP Indigenous Health Incentive) or community members (for example, Healthy Lifestyle Activities). The potential audience (reach) of measures which include a focus on dissemination of information to Aboriginal and Torres Strait Islander people or health workers (for example, Break the Chain, Health Heroes or the Clinical Practice and Decision Support Guidelines) will be determined by the communication strategies used by the individual measures.






Expected timeframes are defined by the Evaluation Framework for each measure; set out in the Evaluation Framework.70 Many of the changes which represent the overarching aims of the ICDP, such as a significant reduction in lifestyle chronic disease risk factors and meaningful improvements in chronic disease outcomes, can only be expected to occur over several years and probably beyond the life of the current evaluation. In the shorter term, project activities, outputs and short term outcomes such as improved workforce capacity and increased community engagement in health initiatives, can be reasonably expected to occur. 4.5 Year one progressThe implementation of ICDP largely progressed as planned which, given its scale, complexity and lead up time, was an important achievement. Not unexpectedly, the implementation of some facets of individual measures took longer than intended and in some cases was deferred to 2010-11.This section provides findings and observations relevant to the ICDP for the baseline year (2009-10). More detailed findings in relation to individual measures can be found in the year one progress sections of chapters Error: Reference source not found to 19. This section is organised into three subsections: key achievements; issues and challenges; and baseline findings against the evaluation objectives.

Key achievements

Implementing such a large and complex package of diverse initiatives across a broad spectrum of health-related focus areas is a significant achievement in itself. In addition, it appears that individual measures stayed largely on track in terms of timelines and funding expenditure during the 2009-10 period. Some slippage in timeframes was to be expected given the scale and complexity of the initiative. However, where slippage in timeframe or budget occurred it seems that a flexible approach was taken to managing delays and expenditure allocations in a manner which supported successful ongoing implementation of the Package. Other achievements in the first year of the ICDP are: Strengthened linkages and relationships between stakeholders.

While the implementation of the ICDP was largely managed from the Central Office of the department to ensure that it was rolled out in a coordinated way in line with the intended policy, it has resulted in closer working relationships at all levels of the department. Many stakeholders who were interviewed through evaluation consultations commented on the imperative for close collaboration to ensure that the various national initiatives could work locally. While the IHPFs predated the ICDP, the ICDP has provided a renewed purpose

70 Urbis Pty Limited 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework . September 2010 , Volumes 1, 2 and 3 , Department of Health and Ageing, Canberra, viewed September 2012.








for these Forums. Finally, at the national level the ICDP has provided a focus for various national peak bodies to work collaboratively on issues arising during the implementation period.

The use of commissioned research to influence critical elements of design including:- a literature review combined with key stakeholder consultations to identify

considerations for the development of the tobacco control social marketing campaign;

- primary research with Aboriginal and Torres Strait Islander people and health care professionals to inform the quit smoking communication strategies;

- primary research to inform the Local Indigenous Community Campaigns to Promote Better Health; and

- primary research to inform the promotional campaign to encourage Aboriginal and Torres Strait Islander secondary school students to take up careers in the health care sector.

It was reported by the various measure managers that the research projects had contributed to the relevant spheres of evidence base. It was also reported that departmental capacity had been greatly increased in relation to communicating with Aboriginal and Torres Strait Islander people and designing good practice policy initiatives in health promotion for Aboriginal and Torres Strait Islander people. Both of these outcomes provide platforms for sustainable change in the department and national health policy.

The establishment of a diverse range of new workforce models. The ICDP incorporates a number of ambitious workforce elements which have resulted in the need to recruit significant numbers of health workers across both the mainstream and Indigenous health service (IHS) sectors. It is well recognised that the health workforce generally suffers a number of chronic limitations, with particular areas of shortage in some professions and across regional and remote locations. While recruiting workers doesn’t automatically translate into outcomes, it is a critical success factor for many of the ICDP measures. Given the significant challenge recruitment in the Aboriginal and Torres Strait Islander (and mainstream) health sector can present, even modest successful recruitment to Aboriginal and Torres Strait Islander health-related positions should be recognised as an achievement.

The establishment or utilisation of various expert reference groups or oversight bodies to guide the implementation of various measures. Examples include the Technical Reference Group set up for the PBS Co-payment (B1) measure and the utilisation of the IHPFs to allocate resources within jurisdictions for some measures. Notwithstanding some of the concerns about the timeliness and scope of consultation discussed in this section, many structures were put in place to gain input from external stakeholders at some point. Given the high level of stakeholder interest in the ICDP discussed






above, it is recognised that these structures have provided a platform to support engagement and buy-in.

The ICDP Monitoring and Evaluation Framework was developed with extensive input from stakeholders and experts. The Sentinel Sites project was progressed during 2009-10 in terms of planning the approach and undertaking procurement to identify a suitable provider.

Issues and challenges

The issues confronted by the ICDP which are identified in this section will be more thoroughly investigated during later stages of the evaluation. At this baseline stage, these issues represent areas of interest both for the department and the evaluation team to focus on as the evaluation progresses. The key issues that have arisen for the ICDP in the first year of implementation can be grouped into three main themes: The need for a more strategic approach to sustaining the ambitious workforce

enhancement aspects of the ICDP. The size of the workforce requirements and the contextual limitations suggest that a highly coordinated strategic approach would be useful to:- clarify the emerging role of new workforce elements in relation to existing

workforce groups such as Aboriginal Health Workers, and workforce developments being pursued by individual state/territory health departments;

- consider how new positions can best complement the existing workforce;- coordinate an approach to ongoing training; - consider the sustainability of the new workforce elements and of the

impact of the workforce initiatives on the health workforce more broadly; and

- manage communication to the sector around the workforce elements both during implementation and beyond.

This issue was discussed in the December 2010 Sentinel Sites report. Specific concerns raised in that report included challenges in recruiting to the Tobacco Action Workers (TAWs) and Healthy Living Worker (HLW) positions due to the real and perceived requirements71, expectations for remote workers to cover excessive distances, and supporting Aboriginal and Torres Strait Islander employment strategies within the mainstream sector.72 Variations in orientation, training and support were also identified as common issues.

71 Relevant Funding Agreements state that these workers must Exemplify non-smoking and quit smoking behaviours. 72 Menzies School of Research 2010, Sentinel Sites Evaluation Report December 2010, Department of Health and Ageing, Canberra.






The overall approach to stakeholder engagement. This was raised as a concern by several stakeholders during evaluation consultations, and although various examples of good stakeholder engagement have been identified, there is a strong view held by some that engagement was lacking in terms of:- a strategic approach to engaging with key stakeholder groups across the

different measures of the ICDP;- opportunities for input into the design phase or to have ongoing input into

monitoring and troubleshooting; and- ongoing information sharing and open communication between the

stakeholders and the department. The need for flexibility in how individual measures can be applied at the local

level balanced against the need to maintain national consistency. The significant diversity of locations, communities and settings in which the ICDP is being implemented makes finding this balance very challenging.

It is important to note that all stakeholders support the broad aims of the ICDP. They see that these issues also present opportunities to enhance the ICDP that will require: greater scope for funded organisations (and representative and peak bodies)

to apply flexible local solutions while ensuring the focus of the funds is maintained (that is, a focus on outcomes rather than processes); and

improved linkages across measures and with other initiatives to ensure that there are no overlaps, and to maximise cross-measure support and synergies.

Finally, there are information limitations that may constrain the monitoring and evaluation of the ICDP. Some limitations are to be expected and arise from the need to consider the impact of gathering and managing data on stakeholders both at the department and service provider level, relative to reasonable requirements to support a robust and informative evaluation. Other limitations arise from the capacity of fund holders to collect the primary data critical to the evaluation. This will be progressively explored in the Monitoring Reports as the evaluation team is able to access measure-specific data reported by fund recipients.4.6 Year one findings against the evaluation objectives This section summarises some key findings organised according to the objectives of the evaluation.

Consistency of the implementation with the original plans as identified in the Evaluation Framework

The evaluation is to consider73 the extent to which the implementation of individual measures and the Package has been consistent with the original plans 73 Urbis Pty Limited 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework . September 2010 , Volumes 1, 2 and 3 , Department of Health and Ageing, Canberra, viewed September 2012.








as represented in the Commonwealth Implementation Plan.74 For the purposes of this Baseline Report, discussion will focus on significant changes to the design of measures which occurred during implementation. This evaluation question will be further explored in the subsequent Monitoring and Final Reports.Overall the Package has been implemented in a manner consistent with the Commonwealth Implementation Plan and the Evaluation Framework. In some cases the design of measures was altered in response to emerging information or enhanced understanding. The workforce components of the National Action to Reduce Indigenous

Smoking Rates (A1) and the Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) measures were combined during implementation to become Regional Tackling Smoking and Healthy Lifestyle Teams (RTSHLTs).75 This move to combine these workforce elements was in recognition that greater support could be provided to and within teams through this approach, in addition to the clear synergies and likely shared target group between the two measures.

The core component of the Local Indigenous Community Campaigns to Promote Better Health (A3) measure was originally planned as a national campaign. However, in 2009 Ipsos SRI was engaged to undertake a literature review that described differences in the way Aboriginal and Torres Strait Islander people view health, wellbeing, self and time compared to non-Aboriginal and Torres Strait Islander people, and how this impacts service and program delivery. Perhaps the single most relevant finding from the literature review was that, given the enormous cultural and social diversity of Aboriginal and Torres Strait Islander communities, health promotion campaigns are best developed and delivered locally with buy-in from key community leaders and health professionals. As such the Local Indigenous Community Campaigns to Promote Better Health (A3) measure was altered to focus on the delivery of local or regional health promotion/social marketing campaigns underpinned by a coordinated national communication and support strategy.

During development of the Clinical Practice and Decision Support Guidelines (C5) measure it became clear that increasing provider access to existing resources was a greater priority than adapting existing clinical practice guidelines to Aboriginal and Torres Strait Islander patients. Therefore the primary focus of the measure became making web-based chronic disease prevention and management resources more accessible to health care providers in IHSs and other primary health care services.

Expert advice or emerging evidence has provided a strong rationale for a change in design in each of these cases.

74 For detail on the Commonwealth Implementation Plan, refer to Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed 6 September 2012. 75 Regional Tobacco Coordinators and Tobacco Action Workers are funded under A1 and Healthy Lifestyle Workers are funded through the A2 measure.




http://www.health.gov.au/internet/main/Publishing.nsf/Content/closinggap-tacklingchronicdisease/$File/commonwealth_implementation_plan.pdf




Synergies among the measures

The evaluation will also examine the extent to which the ICDP and individual measures are consistent and coordinated with, and complementary to, each other and the Package aims. At this stage of the evaluation it is clear that, while the measures often appear to operate independently of one another, there are interdependencies and linkages across the Package. Appendix C summarises the linkages between the ICDP measures as they appear at this Baseline phase of the evaluation. The extent to which linkages between the ICDP measures have been fully capitalised on at the administration or service delivery level seems to vary. At the strategic level, stakeholders have reported that the administration of the ICDP measures by different branches of the department appears to them to have presented some challenges to effective coordination. However, examples of good coordination can be found, with the integrated approach to implementing the National Action to Reduce Indigenous Smoking Rates (A1) and Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) measures providing a clear example. At the service delivery level some providers engaged through the site visits conducted for the Patient Journey and Service Mapping, reported that resource limitations and tight implementation timeframes have presented barriers to collaboration and to creating linkages at the local level. However, through these site visits the evaluation also identified some strong examples of synergies realised at the local level, suggesting that other location-specific or organisational factors may be acting as barriers where this is not the case. For example, the service delivery level coordination between measures is often facilitated by the organisational structure within which measures are implemented – for example IHPOs, ATSIOWs and Care Coordinators may be grouped together in a team under a single management structure, which supports coordination.

Effectiveness of individual measures and the Package as a whole in delivering the results and outcomes

The achievement of outcomes will not be addressed in this report but will be held over to the Monitoring Reports at the end of 2011 and 2012. However, the key achievements outlined below are indicative of progression towards achieving early outcomes.

Appropriateness of individual measures and the Package as a whole

The concept of ‘appropriateness’ is addressed in two ways in this report: Appropriateness of the measures and Package to meet target population and

stakeholder needs. There are two elements to this aspect of appropriateness: i) what was the strength of evidence for the need for action?; and ii) what was the suitability of the action taken?






Overall, the need for action on addressing chronic disease for Aboriginal and Torres Strait Islander people is clearly demonstrated by the existing evidence, and by support from stakeholders. The specific approaches to addressing the various component of need (represented by the individual measures) are also generally well supported by evidence. For example, there seems to be clear evidence to suggest that providing care coordination for patients with complex needs should contribute to better health outcomes. However, for some measures the evidence is less clear and direct. For some measures there is clear evidence supporting a particular approach in a mainstream setting, yet little research has been done to examine the applicability to Aboriginal and Torres Strait Islander patients. For example it is unknown whether practice-level incentives (such as the PIP Indigenous Health Incentive) will be as effective in the IHS sector as they may be in a mainstream setting. The lack of clear supporting evidence for some specific design aspects of the ICDP should be considered in the context of implementing an innovative approach to tackling issues which have proven difficult to address in the past, and is not considered as necessarily negative. For example, the ATSIOW position, which is a completely new role, may prove to be an innovative approach to tackling the issue of Aboriginal and Torres Strait Islander access to primary health care services. The evaluation of the ICDP should add to the evidence base in such cases. The evidence base for each of the ICDP individual measures has been addressed within chapters Error: Reference source not found through 19. Appropriateness, defined as awareness, appreciation and satisfaction of the measures and Package, as described to the evaluation by stakeholders. Preliminary discussion of this concept has been informed primarily by consultation with key national stakeholders and the department. Some key themes from stakeholder consultations on the topic of appropriateness follow. Overall, stakeholders interviewed for this report expressed strong support for

the commitment to closing the health gap evidenced by the significant investment made by the Australian Government. The overall focus on chronic disease was also well supported by stakeholders. All stakeholders expressed a strong desire to be engaged in, and contribute to, the successful implementation of the ICDP.

Some stakeholders believe that the more specific elements of the design of the ICDP, including identifying priorities and design of the individual measures, was not informed by a thorough needs assessment. They consider that there is therefore no clear evidence that the desired outcomes will be achieved, even if there is successful implementation of the ICDP as designed.

As stated above, it is indeed the case that the strength of evidence supporting the design of each individual measure varies somewhat. This may in part be due to the timeframes within which the ICDP was designed and approved. However, it should also be noted that developmental research was undertaken for several measures and was used to adjust the design of those measures.






Some stakeholders also felt that consultation with representative bodies, industry experts and Aboriginal and Torres Strait Islander people regarding the ICDP really began in earnest only after the design had been largely decided, and thus opportunities to influence design elements were limited. This concern was associated with a level of frustration that expert knowledge was not fully engaged to ensure optimal design.

It should be noted that collaborative design was probably limited to some extent by the confidential nature of budget approval processes (both Commonwealth and jurisdictional).However, assessment against the NIRA service delivery principles identifies various ways in which Aboriginal and Torres Strait Islander people have been engaged in the implementation of the ICDP at the national, jurisdictional and community level.4.7 ICDP data The whole of Package evaluation will be informed by various sources including consultation and surveys, in addition to analysis of secondary data sources. Data sources are identified in relation to specific measures (chapters Error: Reference source not found to19) and secondary sources are discussed in Appendix E. For the whole of Package the most important source is the Health Performance Framework. Appendix F contains selected summary statistics as identified in Volume 1 of the Evaluation Framework.76 These statistics establish a baseline for indicators relevant to the ICDP, including Aboriginal and Torres Strait Islander life expectancy at birth, leading causes of mortality, incidence and prevalence rates of chronic disease, prevalence of chronic disease risk factors such as smoking rates, most common reasons for hospitalisation, social and emotional wellbeing, self reported access to health services and number of people in the Aboriginal and Torres Strait Islander health workforce and related education courses. Relevant data will be analysed at different points in time over the evaluation to help assess whether the ICDP is having an impact on these indicators.

76 Urbis Pty Limited 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework . September 2010 , Volumes 1, 2 and 3 , Department of Health and Ageing, Canberra, viewed September 2012.








5. National Action to Reduce Indigenous Smoking Rates

National Action to Reduce Indigenous Smoking Rates (A1) at a glanceICDP priority area: Tackling chronic disease risk factors.The issue being addressed: Smoking rates among Aboriginal and Torres Strait Islander people are much higher (47 per cent for over 15 year olds in 2008) than the rest of the Australian population (between 18 and 22 per cent in 2008).77 Smoking is the most prevalent cause of preventable ill health and early death among Aboriginal and Torres Strait Islander people.78

The ICDP solution: The measure seeks to reduce smoking rates by providing a tackling smoking workforce and workforce supports, plus other national level supports for tobacco reduction. The supporting evidence: Evidence suggests that smoking cessation programs and activities that are designed for Aboriginal and Torres Strait Islander people and communities, and which acknowledge local factors are more likely to be effective than application of mainstream programs with no tailoring. This may include identifying and addressing the most relevant barriers to quitting, and focussing on motivators specific to Aboriginal and Torres Strait Islander communities.The central causal pathway: This measure aims to assist Aboriginal and Torres Strait Islander people to reduce or quit smoking. In order to achieve this outcome, the measure aims to build the capacity of the tackling smoking workforce to facilitate changes in knowledge, attitudes and behaviours amongst Aboriginal and Torres Strait Islander individuals and communities in relation to smoking. Reach: The potential and actual reach of the measure will be determined by the size and distribution of the tackling smoking workforce and the number of Aboriginal and Torres Strait Islander people who are exposed to and/or engage in smoking cessation activities. It is intended that 57 host organisations will be funded across Australia under this measure, with a total of 228 tackling smoking workers employed by 2013. Timeframes: Within two to four years it is expected that the workforce will have improved capacity to provide smoking cessation messages and to support Aboriginal and Torres Strait Islander people, who are expected to increasingly seek support for quit attempts. It is expected that other desired outcomes, most notably a decrease in smoking rates, will occur over a longer period (greater than four years). Year one progress: In 2009-10 key implementation activities, including commissioning research and negotiating funding agreements with host

77 Australian Bureau of Statistics 2009, The health and welfare of Australia’s Aboriginal and Torres Strait Islander people, cat. no. 4704.0, ABS, Canberra.78 Calma, T 2011, ‘Tackling Indigenous Smoking’, Of Substance, 9(2), pp. 28-29.






organisations, were undertaken. 5.1 Design of the National Action to Reduce Indigenous Smoking

Rates measure (also referred to as the Tackling Smoking measure)

The Tackling Smoking measure is delivered through four core components: research; tackling smoking workforce; workforce program supports; and national-level supports. The funding allocation for the Tackling Smoking measure is $100.61 million across the first four years of the ICDP (2009-10 to 2012-13).

Research

Two research projects were commissioned to inform the development of this measure: The first involved a literature review combined with key stakeholder

consultations to identify considerations for the development of “effective, culturally appropriate tobacco control social marketing campaigns for Aboriginal and Torres Strait Islander communities.”79

The second involved primary, qualitative research with Aboriginal and Torres Strait Islander people and health care professionals in all states and territories except the Australian Capital Territory, “to help inform communication strategies that will encourage Indigenous Australians who smoke to quit, and to discourage uptake by those who currently do not smoke.”80 This research explored motivators for quitting or preventing smoking, preferred media channels, and communication needs of different segments of the population.

Tackling smoking workforce

The most substantial component of the measure is the establishment of a tackling smoking workforce, consisting of Regional Tobacco Coordinators (RTCs) and Tobacco Action Workers (TAWs), in 57 host organisations across Australia. Early in the implementation of the measure a decision was made to combine the tackling smoking workforce (RTCs and TAWs) with the Healthy Lifestyle Workers (HLWs) to be funded under the Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) measure. The combined teams became known as Regional Tackling Smoking and Healthy Lifestyle Teams (RTSHLTs). This decision was made to provide better support for the workers, particularly the HLWs, and 79 Carroll Communications 2009, Health promotion and social marketing interventions addressing tobacco smoking in Indigenous communities: time for moving forward, Department of Health and Ageing, Canberra.80 Ipsos-Eureka Social Research Institute and Winangali Pty Ltd 2010, Developmental research to inform the National Action to Reduce Smoking Rates social marketing campaign, Sydney, viewed 16 August 2012.




http://www.health.gov.au/internet/ctg/Publishing.nsf/Content/home-1/$file/Smoking%20Campaigns%20report.pdf




was consistent with advice provided by the Tobacco Technical Reference Group (see section 5.7 for details). RTSHLTs provide health promotion activities on a regional basis (i.e., across their allocated geographical region, which may be broader than the regular service delivery catchment of their host organisation). This may mean that services are being provided in a manner which is in conflict with the hosts organisational mandate or charter. The extent to which this situation impacts on the implementation of the RTSHLTs (i.e., whether it restricts the geographical reach of RTSHLT activities) has not yet been observed, but will be explored further in future evaluation activity. RTCs lead the teams, and are expected to coordinate the work of the RTSHLT in delivering activities appropriate to the local community across their region. They are also expected to “work in partnership with other RTCs and State-based Mentors” and to “collaborate with the National Coordinator, Tackling Indigenous Smoking, to align regional activities with national approaches.”81 TAWs work under the guidance of the RTCs to undertake smoking prevention events and activities. These positions are expected to work in partnership with other TAWs in the region, and within the national network of TAWs coordinated by the National Coordinator, Tackling Indigenous Smoking National Coordinator (see below - Workforce program supports). Information about the role of HLWs is provided in chapter 6. RTSHLTs are expected to liaise with other organisations and workers to develop and implement local health promotion activities, events and materials aimed at smoking cessation and promoting smoke-free environments. These interventions are to be locally appropriate and based on a needs assessment, which is documented in the host organisation’s Regional Action Plan and provided to the National Coordinator for approval. Additional activities include identification of local smoke-free role models, referral of community members for health checks and to lifestyle modification programs, and cooperation with national evaluation activities.82 The department encourages the colocation of all team members in one site/organisation in order to foster collaborative working relationships. Identification as an Aboriginal or Torres Strait Islander person is not a requirement for any of the RTSHLT positions. Priority regions and host organisations for this workforce were recommended by the Indigenous Health Partnership Forums (IHPFs see section 4.1) in each jurisdiction. Host organisations (i.e., fund holders) are generally community controlled IHSs, but may also be Divisions of General Practice/Medicare Locals, state government-run IHSs or other non-government organisations (such as the National Centre of Indigenous Excellence).

81 Department of Health and Ageing n.d., ‘Regional Tobacco Coordinator – Job Description ‘ Schedule 6 – Projects Schedule – Regional Tackling Smoking and Healthy Lifestyle Workforce and Activities, Appendix A, DoHA, Canberra.82 Department of Health and Ageing n.d., ‘Regional Tobacco Coordinator – Job Description ‘ Schedule 6 – Projects Schedule – Regional Tackling Smoking and Healthy Lifestyle Workforce and Activities, Appendix A, DoHA, Canberra.






RTCs are expected to be or become qualified to the Certificate IV level (in a relevant course) during their work term, and TAWs (and HLWs) are expected to be qualified or working towards qualification at the Certificate II or III level. The host organisation is funded to provide the RTSHLT workforce with Certificate level training through a Registered Training Organisation. Workers are expected to have an individual training plan to achieve these qualifications and other competencies in areas such as health promotion and smoking cessation. It is expected that the host organisation will provide the workforce with local orientation. The fund holder arrangements for training the RTSHLT workforce under this measure are different from the training arrangements for the workforce of the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure (Aboriginal and Torres Strait Islander Outreach Workers, Practice Managers and other health positions in IHSs). This difference may lead to administrative challenges for organisations that are fund holders for both the Tackling Smoking and Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure workforce positions. This will be explored further in future evaluation activity. RTSHLT host organisations receive both operational funding and activity funding. Operational funding covers salaries, program administration and management, equipment, set up, training allocation, vehicles and travel/accommodation allowance. The department offers activity funding in the form of project grants from a ‘Regional Tackling Smoking Fund’ (see below - Workforce program supports) for special projects supporting the overall efforts of the RTSHLTs. Grants are built into the funding agreements with host organisations.Host organisations are required to provide a Regional Action Plan for each financial year to the department which outlines how the organisation intends to deliver the funded activities. As a condition of funding, host organisations must develop and implement smoke-free workplace policies by 30 June 2011.

Workforce program supports

The measure includes three types of program supports that are intended to bolster the work of RTSHLTs: a National Coordinator; project grants; and resource kits. The National Coordinator is a ‘champion’ of workforce development, and contributes to decision making regarding community-based tobacco reduction grants. Dr. Tom Calma, a prominent Aboriginal leader, has been appointed to this inaugural position. The National Coordinator is also responsible for approving Regional Action Plans on behalf of the department.Project grants of up to $100,000+GST per region per annum are available through the ‘Regional Tackling Smoking Fund’. Host organisations must submit a business case for use of the Regional Tackling Smoking funds, and must also provide a progress report on their utilisation of grant funding from the Regional Tackling Smoking Fund. It is intended that these funds are used for social marketing, activities, projects and events. An ‘Activity Report Proforma’ reporting template requires grant recipients to describe the outcomes and






objectives, progress or achievements, difficulties, future plans, and case studies relating to use of the grant, as well as to attach any communication materials developed.Each host organisation receives a ‘resource kit’ for the use of the RTSHLTs, including a ‘Resource Pack Guide’ binder that identifies relevant reference materials (e.g., brochures, posters, books) that may be ordered from various sources and a DVD, Smoking, An Indigenous Health Challenge produced by the Rural Health Education Foundation.

National-level supports

The Tackling Smoking measure includes other national-level activities that broadly support a reduction in smoking rates. This includes ‘brief intervention’ training for 1,000 community workers83 and enhancements to the national Quitline.84 Quitline enhancements include hiring additional Aboriginal and Torres Strait Islander staff and cultural awareness training for telephone counsellors. Enhanced Quitline services are delivered within each state/territory with the exception of the Australian Capital Territory and Tasmania. Quitline fund holders are: Preventative Health Directorate, Queensland Health; Cancer Institute New South Wales; Department of Health (Victoria); Cancer Council South Australia; Metropolitan Health Service, Department of Health (Western Australia); and Department of Health and Families (Northern Territory).85

Finally, the Tackling Smoking measure has included funding towards the Aboriginal and Torres Strait Islander-specific ‘Break the Chain’ national media campaign for tobacco reduction.86

Stakeholders

Table 4 below provides an overview of the key stakeholder groups and their roles in relation to the Tackling Smoking (A1) measure since its implementation.

83 Tobacco brief intervention training equips workers to assess participants’ readiness to quit, and to provide appropriate motivation to reduce or eliminate tobacco use. Brief interventions are generally provided opportunistically. 84 Quitline is a state/territory run mainstream telephone based counselling service to support tobacco reduction efforts.85 Based on information provided by the Department of Health and Ageing. 86 Australian Government 2011, National Tobacco Campaign, Break the Chain (website).




http://www.quitnow.gov.au/internet/quitnow/publishing.nsf/Content/ntc-break-the-chain



Table 4: Key stakeholders, roles and communications in relation to the National Action to Reduce Indigenous Smoking Rates (A1) measure.87

Type of stakeholder

Stakeholder Role in National Action to Reduce Indigenous Smoking Rates (A1)

Department stakeholder

Department Central Office

Provide National Coordinator for Tackling Indigenous SmokingDevelop resource kitsManage contracts with fund holders


Department state/territory offices

No direct role in this measure


Tobacco Technical Reference Group

Provide advice to the department on implementation, including identification of networks, possible performance indicators, and emerging risks


Campaign Reference Group

Provide input on activities related to social marketing (see also Local Indigenous Community Campaigns to Promote Better Health (A3) measure)

Workforce stakeholder

IHPFs Identify priority regions and fund holder organisations for RTSHLT implementation


Indigenous health services

Fund holders (host organisations) for tackling smoking workforceImplement workforce componentReport to the department on implementation


Divisions of General Practice / Medicare Locals

As above


Regional Tobacco Coordinators

Coordinate workforce activitiesLiaise with other RTSHLTsDeliver A1 health promotion activities and events


Tobacco Action Workers

Deliver A1 health promotion activities and events






Type of stakeholder

Stakeholder Role in National Action to Reduce Indigenous Smoking Rates (A1)


Aboriginal and Torres Strait Islander community members

Participate in A1 tobacco reduction activities provided by RTSHLTs

Quitline enhancement project stakeholders

State government bodies

Fund holders for Quitline enhancementDesign/implement Quitline enhancements


Quitline counsellors

Deliver enhanced Quitline services


Aboriginal and Torres Strait Islander clients

Utilise enhanced Quitline services

Brief intervention training stakeholders

Trainers Provide training in tobacco brief interventions


Training recipients

Gain skills in tobacco brief intervention


Aboriginal and Torres Strait Islander people who receive tobacco brief interventions

Receive brief interventions for quitting smoking


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).88 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Tackling Smoking measure. 88 Council of Australian Governments 2011, National Indigenous Reform Agreement (Closing the Gap), Schedule D, viewed September 2012.








Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. This measure aims to reduce the incidence of preventable chronic disease by

reducing a key risk factor – smoking. RTSHLTs provide locally appropriate programs, activities and education based

on needs assessments developed by RTCs. Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. The measure is premised on a community development approach that

depends on the engagement of local communities and groups in health promotion activities and events.

Fund holders for the RTSHLTs are recommended by the IHPFs; IHPF membership includes representation from the Commonwealth, and state/territory governments and the Aboriginal community controlled sector, including Aboriginal and Torres Strait Islander people.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The Tackling Smoking measure is funded over the first four years – 2009-10

to 2012-13. The focus of this measure is building workforce capacity and sustainable changes in community attitudes and behaviours, as to ensure longevity beyond the initial funding timeframe. The sustainability of the program will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. A core role of the RTSHLTs is community engagement and it is intended that

programs and activities are provided in a range of community-based settings. The design of the measure aims to achieve national coverage: RTSHLTs are

being implemented in 57 regions across Australia, covering urban, rural and remote areas, and are intended to provide services across a region (not limited to the catchment area of the host organisation).

In addition, the Tackling Smoking measure incorporates national enhancements, such as for Quitline services which are available across Australia to people with access to telephones and/or the internet.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. The workforce component of the measure requires collaboration between

state and territory governments and the IHPFs to better coordinate complementary activities in the jurisdictions.

In addition, Quitline enhancements projects involve state and territory governments as fund holders.






Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. Fund holders for this measure provide regular formal reporting to the

department as required in the funding agreements. The Tackling Smoking measure is included in two ICDP evaluation projects –

the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

In addition, the Tackling Smoking measure is subject to ongoing monitoring and public reporting in the Tackling Smoking measure Annual Report.

5.2 Rationale and supporting evidenceThe measure responds to the high prevalence of tobacco use by Aboriginal and Torres Strait Islander people and the resulting health impacts. Smoking is the most preventable cause of ill health and early death among Aboriginal and Torres Strait Islander people which in 2003 was responsible for one in five of all deaths in this population.89 Figure 2 below shows the estimates of current smokers from the most recent iterations of each of the ABS surveys (the NATSISS and NATSIHS) which were collected in 2008, 2004-05 and 2002. An estimated 76,200 Aboriginal and Torres Strait Islander males and 76,800 Aboriginal and Torres Strait Islander females aged 15 years and over were current smokers in 2008 according to the NATSISS. This was just under half of the male (49 per cent) and female (45 per cent) Aboriginal and Torres Strait Islander population respectively in 2008.

89 Calma, T 2011, ‘Tackling Indigenous Smoking’. Of Substance, 9(2), pp. 28-29.62





0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

2002 NATSISS 2004-05 NATSIHS 2008 NATSISSPerc

enta

ge of

Abo

rigina

l and

Torre

s St

rait I

sland

er p

opula

tion

Current Smoker RSE Lower RSE Upper

Figure 2: Estimates of the proportions of Aboriginal and Torres Strait Islander people that are current smokers, 2002-2008.90,91

Although Figure 2 displays a downward trend in smoking in recent years, there was no significant difference in the rates of smoking between the 2008 NATSISS and the previous 2004-2005 NATSIHS and 2002 NATSISS. This suggests that the rates of smoking amongst Aboriginal and Torres Strait Islander adults have remained relatively stable since 2002.In addition, smoking during pregnancy is three times more common among Aboriginal and Torres Strait Islander women than other Australian women. The data presented in Figure 3 below shows that the rate of Aboriginal and Torres Strait Islander women smoking during pregnancy, for the period from 2006 to 2008.

90 Australian Bureau of Statistics 2006a, National Aboriginal and Torres Strait Islander Health Survey 2004–05. ABS cat. no. 4715.0, ABS, Canberra. Australian Bureau of Statistics 2002, National Health Survey: Aboriginal and Torres Strait Islander Results, Australia, 2001, ABS, Canberra; Australian Bureau of Statistics 2008, National Aboriginal and Torres Strait Islander Social Survey 2008, ABS cat. no. 4714.0, ABS, Canberra.91 Note: this figure presents the current smoking rates, alongside the relative standard error (RSE) lower and upper values. As the ‘current smoker’ rate is a national estimate, the RSEs show the likely range across which the true smoking rate is likely vary amongst different populations.






0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

2006 2007 2008Perc

enta

ge of

Abo

rigina

l and

Torre

s St

rait I

sland

er m

othe

rs

Indigenous Mothers Smoking during pregnancy

Figure 3: Percentage of Aboriginal and Torres Strait Islander women who smoked during pregnancy, 2006-2008.92 Although there was again, a slight decrease in rates over 2006-2008, this figure shows that smoking during pregnancy has also remained relatively stable, at just over 50 per cent between 2006 and 2008. Aboriginal and Torres Strait Islander children 0-14 years have three times the likelihood of being exposed to second hand smoke in the home.93,94 Smoking is associated with poor perinatal outcomes such as low birth weight (less than 2,500 grams)95, pre-term birth, foetal growth restriction, congenital anomalies and perinatal death. Despite high smoking rates, in 2008, 62 per cent of Aboriginal and Torres Strait Islander daily smokers indicated they wanted to quit or reduce their smoking.96

Evidence related to the RTSHLT workforce and smoking cessation activities

Various factors are believed to be contributors to high smoking rates among Aboriginal and Torres Strait Islander people including stress, normalisation of smoking,97 insufficient understanding of the risks98 and continuity between

92 Li Z, McNally L, Hilder L & Sullivan EA 2011, ’Australia’s mothers and babies 2009 (and 2008, 2007)’, Perinatal statistics series no. 25. Cat. no. PER 52, AIHW National Perinatal Epidemiology and Statistics Unit, Sydney.93 Australian Health Ministers’ Advisory Council 2011, Aboriginal and Torres Strait Islander Health Performance Framework Report, 2008, 2.03, AHMAC, Canberra.94 Calma, T 2011, ‘Tackling Indigenous Smoking’. Of Substance, 9(2), pp. 28-29.95 Australian Institute of Health and Welfare 2005, A picture of Australia’s Children, AIHW, Canberra.96 Australia Bureau of Statistics 2009, The health and welfare of Australia’s Aboriginal and Torres Strait Islander people, cat. no. 4704.0, ABS, Canberra.






current and past patterns of tobacco use.99 Recent research with the Aboriginal and Torres Strait Islander population suggests that addressing some of these factors, as well as the barriers to quitting and the motivators for change may be effective components of tobacco cessation interventions. Barriers to quitting include limited access to services that support quitting within some Aboriginal and Torres Strait Islander communities,100 incorrect beliefs about the risks associated with smoking101 and proximity to a partner and/or friends who smoke.102 Motivators to change may include the impact of smoking on family members and particularly on children (health impacts); the costs of cigarettes and the impact on family budgets; encouragement from others; and recognition of the adverse impacts of smoking on sport performance.103,104 There is limited tobacco cessation research specific to the Aboriginal and Torres Strait Islander population.105 However, the current evidence base indicates that: Multi-component tobacco campaigns involving on the ground tobacco

cessation activity and a combination of initiatives (e.g., sports sponsorship; health promotion campaigns; training health professionals in the delivery of smoking cessation advice; school education about tobacco; and policies on smoke-free public places) can result in reductions in tobacco consumption within Aboriginal and Torres Strait Islander communities.106 There is a positive

97 Centre for Excellence in Indigenous Tobacco Control n.d., Just the Facts: A fact sheet about tobacco use among Indigenous Australians, CEITC, Victoria. 98 Gilligan C, Sanson-Fisher RW, D’Este C, Eades S & Wenitong M 2009, ‘Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women’, Medical Journal of Australia, vol. 190, no. 10, pp. 557-561.9999 Brady M 2002, ‘Historical and cultural roots of tobacco use among Aboriginal and Torres Strait Islander people’, Australian and New Zealand Journal of Public Health, vol. 26, no. 2, pp. 120-124.100 Brady M 2002, ‘Historical and cultural roots of tobacco use among Aboriginal and Torres Strait Islander people’, Australian and New Zealand Journal of Public Health, vol. 26, no. 2, pp. 120-124.101 Ipsos-Eureka Social Research Institute and Winangali Pty Ltd 2010, Developmental research to inform the National Action to Reduce Smoking Rates social marketing campaign, Sydney, viewed 16 August 2012.102 Gilligan C, Sanson-Fisher RW, D’Este C, Eades S & Wenitong M 2009, ‘Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women’, Medical Journal of Australia, vol. 190, no. 10, pp. 557-561.103 Ipsos-Eureka Social Research Institute and Winangali Pty Ltd 2010, Developmental research to inform the National Action to Reduce Smoking Rates social marketing campaign, Sydney, viewed 16 August 2012.104 Centre for Excellence in Indigenous Tobacco Control n.d., Just the Facts: A fact sheet about tobacco use among Indigenous Australians, CEITC, Victoria. 105 Power J, Grealy C & Rintoul D 2009, ‘Tobacco interventions for Indigenous Australians: a review of current evidence’, Health Promotion Journal of Australia, vol. 20, no. 3, pp. 186-194.106 Ivers R, Castro A, Parfitt D, Bailie R, Abbs P & Richmond RL 2006, ‘Evaluation of a multi-component community tobacco intervention in three remote Australian Aboriginal communities’, Australian and New Zealand Journal of Public Health, vol. 30, no. 2, pp. 132-136.










relationship between the number of tobacco control activities in place within communities, and the likelihood of reductions in smoking.107

Provision of brief advice and interventions to support smoking cessation by health professionals working in mainstream health services can support smokers to quit. This includes advice on how to quit, support in the quitting process108,109 and interventions such as counselling.110

The introduction of smoke-free places in conjunction with other approaches (e.g., brief intervention training for health professionals; promotion of Quitline) can be effective in reducing tobacco consumption, increasing willingness to quit and increasing knowledge about the health impacts of tobacco.111

Smoke-free policies in Aboriginal and Torres Strait Islander workplaces may be seen as acceptable,112 however, there is no specific evidence about the impact of smoke-free workplaces when implemented alone.

Free nicotine patches and brief intervention (whether in conjunction or alone) may result in reduced smoking and/or cessation, with an increased effect when these interventions are delivered together.113 Other pharmaceuticals such as Varenicline (Champix®), when used in conjunction with counselling, have led to a tobacco abstinence rate of almost twice that resulting from counselling alone.114

The presence of project champions and high levels of community engagement are factors supporting program success and sustainability.115

Health professionals having a core role in tobacco cessation has been shown to be a key factor for quitting success, particularly when support for quitting is 107 Thomas D, Johnston V & Fitz J 2010, ‘Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory ‘Tobacco Project’, Australian and New Zealand Journal of Public Health, vol. 34, pp. 45-49. 108 Stead LF, Bergson G & Lancaster T 2008, ‘Physician advice for smoking cessation (Review)’, The Cochrane Database of Systematic Reviews, Issue 2, John Wiley & Sons Ltd, United Kingdom.109 Rice VH & Stead LF 2009, ‘Nursing interventions for smoking cessation (Review)’, The Cochrane Database of Systematic Reviews, Issue 1, John Wiley & Sons Ltd, United Kingdom.110 Lancaster & Stead LF 2008, ‘Individual behavioural counselling for smoking cessation (Review), The Cochrane Database of Systematic Reviews’, Issue 4, John Wiley & Sons Ltd, United Kingdom.111 Ivers R, Castro A, Parfitt D, Bailie RS, D’Abbs PH & Richmond RL 2005, The Tobacco Project, Cooperative Research Centre for Aboriginal Health, Darwin.112 Seibold M 2000, Indigenous Tobacco Control Pilot Project: Process Evaluation, Workplace Policy

Development Pilot, Phase One, Queensland Health, Brisbane.113 Ivers R, Farrington M, Burns CB, Abbs P, Richmond RL & Tipiloura 2003, ‘A study of the use of free nicotine patches by Indigenous people’, Australian and New Zealand Journal of Public Health, vol. 27, no. 5, pp. 486-490.114 Cahill K, Stead LF & Lancaster T 2010, ‘Nicotine receptor partial agonists for smoking cessation’, Cochrane Database of Systematic Reviews,12:CD006103.115 Wakerman J, Chalmers EM, Humphreys JS, Clarence CL, Bell AI, Larson A, Lyle D & Pashen DR 2005, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183, no. 10, pp. S64-S68






provided.116,117 However, there are a number of barriers for Aboriginal and Torres Strait Islander health professionals delivering tobacco cessation activities. These include a perception that other chronic disease risk factors are more problematic than smoking, fear of appearing hypocritical (if they themselves smoke), and cultural concerns about telling others ‘what to do’.118

Evidence related to program supports for RTSHLTs and national-level supports for tobacco reduction

Developmental research conducted for this measure119 found that community campaigns aiming to prevent smoking amongst Aboriginal and Torres Strait Islander people should be tailored to this population, and suggested further targeting within this population according to life stage and associated barriers, perceptions and needs. The research also found that a range of communication channels should be utilised, including television, radio, and billboards/posters. These findings are supported by other research which shows: television campaigns can be an effective mechanism to improve education

and reinforce health messages from other sources120; successful programs are targeted in their approach121 it is strongly

acknowledged in the literature that ‘blanket’ application of strategies that work with mainstream populations may not be effective;122 but

national media campaigns such as the National Tobacco campaign (which was delivered in conjunction with the Quitline support service) can lead to a reduction in smoking prevalence.123

116 Rice VH & Stead LF 2009, ’Nursing interventions for smoking cessation (Review)’, The Cochrane Database of Systematic Reviews, Issue 1, John Wiley & Sons Ltd, United Kingdom.117 Stead LF, Bergson G & Lancaster T 2008, ‘Physician advice for smoking cessation (Review)’, The Cochrane Database of Systematic Reviews, Issue 2, John Wiley & Sons Ltd, United Kingdom.118 Pilkington A, Carter O, Cameron A & Thompson S 2009, ‘Tobacco control practices among Aboriginal health professionals in Western Australia’, Australian Journal of Primary Health, vol. 15, no. 2, pp152-158.119 Ipsos-Eureka Social Research Institute and Winangali Pty Ltd 2010, Developmental research to inform the National Action to Reduce Smoking Rates social marketing campaign, Sydney, viewed 16 August 2012.120 Ivers R, Castro A, Parfitt D, Bailie RS, Richmond RL & D’Abbs PH 2005, ‘Television and delivery of health promotion programs to remote Aboriginal communities’, Health Promotion Journal of Australia, vol. 16, no. 2, pp. 155-158.121 Sherman EJ & Primack BA 2009, ‘What Works to Prevent Adolescent Smoking? A Systematic Review of the National Cancer Institute's Research-Tested Intervention Programs’, Journal of School Health, vol. 79, no. 9, pp. 391-399.122 Ivers R 2011, Anti-tobacco programs for Aboriginal and Torres Strait Islander people, Resource Sheet no. 4, produced for Closing the Gap Clearinghouse, Australian Institute of Health and Welfare, Canberra & Australian Institute of Family Studies, Melbourne.123 National Tobacco Campaign 1999, Australia's National Tobacco Campaign: Evaluation Report

Volume 1, Commonwealth Department of Health and Aged Care, Canberra.67







A review of the brief intervention resource kits designed to address ‘SNAP’ risk factors124 (smoking, poor nutrition, alcohol misuse, physical inactivity) among the Aboriginal and Torres Strait Islander population found that resources for chronic disease prevention and management should: be provided in an appropriate format (e.g., flipchart, package); include the brief intervention components (e.g., stages of change approach); provide accurate content (as per evidence-based understandings); use plain English for patient brochures and information; and be culturally appropriate to the context. 5.3 The central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving a reduction in Aboriginal and Torres Strait Islander smoking rates as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred by the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Supports are effectively

implemented and evidence based

Individual communities are

receptive to change

Increase in knowledge and understanding of the

dangers and risks associated with smoking

National Action to Reduce Indigenous Smoking Rates

Change in attitudes towards taking up smoking

and quitting smoking

Reduced smoking rates through a reduction in new smokers and an increase in people quitting smoking

Reduced chronic disease risk factors

Recruitment, retention and capacity building

of the workforce

Individual communities are receptive to

messages

Figure 4: Tackling Smoking measure causal model. Source: KPMG. 5.4 Reach and timeframesThe potential reach125 of the National Action to Reduce Indigenous Smoking Rates (A1) measure will be determined by a number of factors including most notably: the number and distribution of the tackling smoking workforce; and

124 Clifford A, Jackson PL, Richmond R, Shakeshaft A & Ivers R 2010, ‘Brief intervention resource kits for Indigenous Australians: generally evidence-based, but missing important components’, Australian and New Zealand Journal of Public Health, vol. 34, no. S1, pp. s80-s86.125 The term ‘reach’ in this Report refers to the potential and actual penetration of the measure’s impact on the intended target group.






the number of Aboriginal and Torres Strait Islander people who are exposed to and/or engage in activities provided as a result of the measure (note, this is likely to be influenced by the individual differences in motivators and barriers to quitting, and how regional smoking cessation activities respond to these in each community).

It is intended that 57 host organisations will be funded across Australia under this measure with a total of four tackling smoking workers in RTSHLTs in each location by 2013.126 This totals 228 tackling smoking workers. No corresponding targets have been set for the number of Aboriginal and Torres Strait Islander people to be engaged by these RTSHLTs.As early results (years 2 – 4) the measure is anticipated to result in: for the workforce: RTCs and TAWs having the knowledge and skills to provide

smoking prevention and cessation activities and communications; health care professionals having better access to smoking cessation resources to support their own cessation attempts; and workers having the knowledge and skills to deliver brief interventions;

for participating community members: improved understanding of health risks associated with smoking and of the resources available for smoking cessation; increased assistance seeking and utilisation of services as part of quit attempts; increased participation in brief interventions; and reductions in levels of smoking; and

at a systems level: an increased evidence base on effective community-based tobacco reduction through the commissioned research underpinning the design of the measure, as well as through feedback from the evaluation, and a Quitline capable of providing culturally relevant, accessible services.

Over the medium to longer term (beyond the first four years) the measure is anticipated to result in: for the workforce: primary health care practices which have increased and

sustainable capacity to provide smoking prevention and cessation activities and communications – both alone and through development of partnerships; and

for the community: increased and sustainable community engagement and demand for smoking cessation activities.

5.5 Complementary activityA number of mainstream, national and state and territory agendas are also working towards decreasing smoking rates amongst the general population and the Aboriginal and Torres Strait Islander population. Refer to Appendix D for more information on Policy Maps which identify these complementary activities.In some cases (e.g., in South Australia and New South Wales), the resources and support available in jurisdictions have supplemented what is provided through

126 Initially RTSHLTs will have four workers – a RTC, a TAW and two HLWs. It is planned that in 2012 and 2013, an additional TAW will be added to each RTSHLT annually, to total six RTSHLT team members in 2013.






ICDP. At the same time, coordination among jurisdictions regarding tobacco reduction is not formal and may not fully identify opportunities for collaboration, resulting in potential duplication. This will be explored further in future evaluation activity. In addition, the naming of the Regional Tobacco Coordinators has been a point of confusion within states/territories that also provide positions with the same title. This has led to stakeholders mistakenly contacting the department with enquiries unrelated to the ICDP funded positions. Within the ICDP itself, the aims of the Tackling Smoking measure are most consistent with those of the Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) and the Local Community Campaigns (A3) measures which also seek to reduce chronic disease risk factors, including smoking. Measures which seek to enhance Aboriginal and Torres Strait Islander people’s access to primary health care127 also have the potential to contribute to a reduction in smoking if primary health care providers are providing information and supports around smoking cessation. The Subsidising PBS Medicine Co-payments (B1) may increase access to medicines, such as nicotine replacement therapies, which will assist people to successfully quit smoking, and may increase people’s motivation to attempt to quit.Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. 5.6 National Action to Reduce Indigenous Smoking Rates data

sourcesEvaluation of this measure will be informed by a range of primary data sources such as consultation with key stakeholders, RTSHLTs, host organisations and community members, health workforce and organisational surveys, and review of program documentation. Secondary data sources such as MBS and Quitline data will be used in year four (2012-13) to assess the impact of RTSHLT activities on participants’ utilisation of relevant health and assistance services. PBS data will be used annually throughout the evaluation for the same purpose. Office for Aboriginal and Torres Strait Islander Health (OATSIH) Services Reporting (OSR) data will also be used, to assess the local smoking prevention and cessation services and programs that have been designed and delivered by RTSHLTs. Further information about these secondary data sources is provided in Appendix E. In addition to these sources, a number of other secondary data sources can be of use to assess relevant historical trends and changes in smoking rates throughout the evaluation. These include: S100 Remote Area Aboriginal Health Service (RAAHS) Supply Program data; National Aboriginal and Torres Strait Islander Social Survey (NATSISS) and

National Aboriginal and Torres Strait Islander Health Survey (NATSIHS); and127 For example, Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a), Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3).






National Perinatal Data Collection (NPDC).A discussion of these other secondary data sources, their relevance to the evaluation and their limitations is also provided in Appendix E.The Evaluation Framework128 identifies a number of quantitative indicators to measure the impact of the whole of Package; some of these are directly relevant to this measure. These are: Proportion of adults who smoke regularly, reported in section 2.18 of the

Health Performance Framework (HPF). In 2008, 47 per cent of Aboriginal and Torres Strait Islanders aged 15 years and over were current smokers, and 45 per cent were daily smokers.

Proportion of mothers who smoked during pregnancy, reported in section 2.19 of the HPF. The rate was 50 per cent in 2007.

Proportion of children exposed to environmental smoke, reported in section 2.03 of the HPF. The rate was 65 per cent in 2007-08.

Refer to Appendix F for further information about these indicators, including original sources. The evaluation will monitor and provide updates on these indicators as they become available.5.7 Year one progress

Key activities

In the baseline year, implementation of the Tackling Smoking measure mainly involved research activities, convening measure reference groups, and establishment of funding agreements. As discussed in section 5.1, two research projects were commissioned during 2009-10 to inform the design of this measure. In 2009-10 a Tobacco Technical Reference Group was established to provide expert advice to the department on implementation of the Tackling Smoking measure, including identification of networks, possible performance indicators, and emerging risks.129 Membership of the Reference Group included representation from the department and the Aboriginal community controlled sector, as well as from health organisations and representative bodies such as the AGPN. The group met three times over the 2009-10 year. A Campaign Reference Group was also established to provide input on activities related to social marketing for this measure as well as the Local Indigenous Community Campaigns to Promote Better Health (A3) measure. In 2009-10 funding agreements were executed for the RTSHLTs and Quitline. The twenty priority regions selected for location of RTSHLTs were offered funding in June 2010. Due to this June date, no RTCs or TAWs were recruited in 2009-10.

128 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.129 Department of Health and Ageing n.d., Tobacco External Technical Reference Group, Commonwealth’s Indigenous Chronic Disease Package.








All states and territories, with the exception of Tasmania, submitted proposals to the department for funding Quitline enhancements, and funding agreements for these projects were executed for all of these fund holders in November 2009, with the exception of Northern Territory and Victoria. An additional key activity in this financial year was the appointment of Dr. Tom Calma as the National Coordinator for Tackling Indigenous Smoking.The 2009-10 expenditure on this measure was $3.18 million.Three performance indicators for this measure are included in the Commonwealth Implementation Plan. They are: number of tobacco action coordinators; number of Indigenous participants in smoking cessation and support

activities; and number of health workers and community educators trained in smoking

cessation.130

Given that recruitment commenced in 2010-11, progress against these indicators is not relevant for 2009-10. Training in brief interventions was not scheduled to commence until 2010-11.

Historical trends and progress against indicators in year one

Secondary data collected prior to or during the 2009-10 year provides information about the use of medicines for treating nicotine dependence and delivery of smoking prevention and cessation programs.There are various medicines available on the PBS to treat nicotine dependence.131 Figure 5 below shows the total amount of these medicines supplied in Australia under the S100 RAAHS Supply Program between July 2008 and June 2010.132

130 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.131 E.g., Nicotine patches such as Varenicline (Champix®), bupropion hydrochloride (Prexaton® and Zyban®).132 Under the S100 RAAHS Supply Program, clients of approved remote area IHSs are able to receive medicines from the IHS without the need for a normal PBS prescription form, and without cost to the patient.






Figure 5: Nicotine dependence items supplied under S100 RAAHS Supply Program arrangements – by month, Jul 2008 – May 2010.133 As this figure shows there was an increase in the number of prescriptions for nicotine dependence medicines over 2008-2010. Specifically, this data shows that the number of smoking cessation medicines supplied under S100 RAAHS Supply Program arrangements almost doubled between 2008-09 and 2009-10, i.e., an 83 per cent increase. In comparison, all medicines supplied under S100 RAAHS Supply Program arrangements increased by just 6.2 per cent over the same period.Just over 90 per cent of all supplied nicotine dependence medicines were for Queensland, Western Australia and the Northern Territory; with the Northern Territory having over 50 per cent of all supplied items. This reflects the relative remoteness of these states and territories and corresponds with the distribution of all S100 RAAHS Supply medicines, with over 90 per cent of all supplied medicines being for these three jurisdictions.This data suggests that the use of medicines for nicotine dependence is increasing significantly, at least in remote areas. The upward trend is likely to have been due to a range of factors including: a number of new nicotine dependence medicines being listed on the PBS in 2008134; the introduction of nurse prescribing; and additional IHSs becoming eligible to be suppliers under the S100 RAAHS Supply Program. Monthly spikes are likely to be consequences of batched purchasing/ordering behaviour by IHSs. Table 5 below presents data on the volumes of medicines and rates of supply (per 1,000 people) for remote and very remote Aboriginal and Torres Strait Islander populations. The rate at which medicines for nicotine dependence were

133 Based on PBS data supplied by the Department of Health and Ageing. 134 Such as the 1mg Champix® tablet (PBS code 9129L) and the Nicorette® Transdermal 15mg patch (PBS code 9198D).






supplied under the S100 RAAHS Supply Program grew by around 33 per 1000 persons between 2008-09 and 2009-10. Below is data on the volumes of medicines and rates of supply (per 1,000 people) for remote and very remote Aboriginal and Torres Strait Islander populations. The rate at which medicines for nicotine dependence were supplied under the S100 RAAHS Supply Program grew by around 33 per 1000 persons between 2008-09 and 2009-10. Table 5: Nicotine replacement medicines supplied under the S100 RAAHS Supply Program, by state/territory.135,136 ,137,138

Summary Statistic NSW QLD WA NT SA TAS TotalRemote and very remote Aboriginal and Torres Strait Islander population

3,971 15,996

15,271

25,076 2,573 N/A 62,8

87

Nicotine replacement medicines in 2008-09 54 335 437 1,137 50 N/A 2,01

6Per 1000 persons in 2008-09 14 21 29 45 19 N/A 25

Nicotine replacement medicines in 2009-10 40 593 734 2,103 171 32 3,67

3Per 1000 persons in 2009-10

10 37 48 84 66 N/A 58

OATSIH Services Report (OSR) data provides information about the delivery of tobacco use treatment and prevention programs delivered by OATSIH funded IHSs. 135 Based on PBS data supplied by the Department of Health and Ageing. 136 These are the only published estimates of the Aboriginal and Torres Strait Islander population by state and remoteness. The limitation of using the same population estimate is that the rates (per 1,000 persons estimates) will most likely over-estimate the rate with each subsequent year. This is because the denominator (the remote and very remote population) will remain static when it is most likely increasing.137 Estimates are of the Aboriginal and Torres Strait Islander population in remote and very remote communities as at June 2006. Australian Bureau of Statistics 2008, Experimental Estimates of Aboriginal and Torres Strait Islander Australians, Jun 2006 , ABS cat. no. 3238.0.55.001, ABS, Canberra. Table 1: Experimental estimated resident Australian Indigenous population, States and territories, Remoteness Areas–5-year age groups (to 65 and over)–30 June 2006.138 The Experimental Estimates of Aboriginal and Torres Strait Islander Australians publication is updated with every population census (i.e., every five years). While the Aboriginal and Torres Strait Islander population is growing, a decision was made to utilise the figures as published by ABS. The justification for this decision was that: These are the only published estimates of the Aboriginal and Torres Strait Islander population by state and remoteness; the estimates are “experimental” and there would be difficulty identifying (and justifying) appropriate growth rates by jurisdiction and remoteness. The limitation of using the same population estimate is that the rates (per 1,000 persons estimated) will most likely over-estimate the rate with each subsequent year. This is because the denominator (the remote and very remote Aboriginal and Torres Strait Islander population) will remain static when the true population is most likely increasing.






Table 6 below shows the number of OATSIH funded IHSs which reported provision of tobacco use treatment and prevention programs, by service type, program type and year, across 2008-09 and 2009-10. Table 6: Number of services using OSR which reported providing tobacco use treatment and prevention programs: by service type, program type and year; 2008-09 to 2009-10.139

Service type Summary Statistic 2008-09(# of services)

2009-10(# of services)

Aboriginal and Torres Strait Islander Primary Health Care Services

Tobacco Control Programs 100 113


Providing treatment and assistance to individual clients with tobacco/nicotine issue

163 184


Providing treatment and assistance for tobacco/nicotine use through programs focused on tobacco/nicotine

66 69


Providing activities to manage tobacco/nicotine use through a tobacco control program

94 106


Providing group activities for tobacco use treatment/prevention

51 69

139 Australian Institute of Health and Welfare 2011, Aboriginal and Torres Strait Islander health services report 2009–10: OATSIH Services reporting — key results, cat. no. IHW 56, AIHW, Canberra. Australian Institute of Health and Welfare 2010, Aboriginal and Torres Strait Islander health services report 2008–09: OATSIH Services reporting — key results, cat. no. IHW 31, AIHW, Canberra.






Service type Summary Statistic 2008-09(# of services)

2009-10(# of services)

Aboriginal and Torres Strait Islander stand-alone substance use services

Providing substance use services or programs to individual clients

34 35


Providing programs focused on tobacco/nicotine

22 25


Providing activities to manage tobacco/nicotine use through a tobacco control program (services that provide residential treatment)

13 14


Providing activities to manage tobacco/nicotine use through a tobacco control program (services that do not provide residential treatment)

1 2



20 27

Aboriginal and Torres Strait Islander Bringing Them Home and Link Up services


12 11

As detailed above, there was an increase in the number of primary health care and stand-alone substance use services providing tobacco cessation and treatment programs between 2008-09 and 2009-10. The number of Aboriginal and Torres Strait Islander Bringing Them Home and Link Up services providing tobacco programs reduced by one service. This suggests that, overall, the number of tobacco use treatment and prevention programs available for Aboriginal and Torres Strait Islander people is increasing.






6. Helping Indigenous Australians Reduce Their Risk of Chronic Disease

Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) at a glanceICDP priority area: Tackling chronic disease risk factors.The issue being addressed: Lifestyle risk factors, including poor nutrition and physical inactivity, are significant contributors to chronic disease amongst Aboriginal and Torres Strait Islander communities.The ICDP solution: The measure seeks to improve lifestyle choices by funding Healthy Lifestyle Workers (HLWs) to undertake health promotion activities in Aboriginal and Torres Strait Islander communities. HLWs operate as a part of Regional Tackling Smoking and Healthy Lifestyle Teams (RTSHLTs), which are part of the National Action to Reduce Smoking Rates (A1) measure. The supporting evidence: Available evidence suggests that multi-component health promotion activities can be effective in addressing chronic disease risk factors140, particularly when they are contextually relevant, and culturally appropriate.141,142,143

The central causal pathway: This measure aims to assist Aboriginal and Torres Strait Islander people to increase their healthy lifestyle choices in order to reduce chronic disease risk factors. In order to achieve this outcome, the measure provides a workforce to facilitate changes in knowledge, attitudes and behaviours amongst Aboriginal and Torres Strait Islander individuals and communities in relation to healthy lifestyle choices.Reach: The potential and actual reach of the measure will be determined by the number and distribution of the HLWs and the number of Aboriginal and Torres Strait Islander people who are exposed to and/or engage in activities provided as a result of the measure. Timeframes: Within two to four years, it is expected that the workforce will have improved capacity to provide healthy lifestyle activities to Aboriginal and Torres Strait Islander people, who are expected to increasingly utilise supports

140 Coppell KJ, Tipene-Leach DC, Pahau HLR, Williams SM, Abel S, Iles M, Hindmarsh JH & Mann, JI 2009, ‘Two-year results from a community-wide diabetes prevention intervention in a high risk indigenous community: the Ngati and Healthy project‘ Diabetes Research and Clinical Practice, vol. 85, no. 2, pp. 220-227.141 Jamieson S & Heron B 2009, ‘Evaluating the effectiveness of a healthy cooking class for Indigenous youth’, Aboriginal and Islander Health Worker Journal, vol. 33, no. 4, pp 6-9.142 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health, Sydney.143 Griew R 2008, The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.






for healthy living choices. As a result it is expected that desired behavioural changes will increase and be sustained over a longer period. Year one progress: In the ICDP baseline year (2009-10) the key activities included negotiating funding agreements with host organisations, and identifying HLW training needs. 6.1 Design of the Helping Indigenous Australians Reduce their Risk

of Chronic Disease measure (also referred to as the HLW measure)

Core component: Healthy Lifestyle Workers (HLWs)

The Tackling Smoking (A1) measure and this HLW (A2) measure were originally designed to operate independently. In practice, however, HLWs have been integrated into Regional Tackling Smoking and Healthy Lifestyle Teams (RTSHLTs) together with TAWs and RTCs. These teams operate within host organisations, which are primarily Aboriginal community controlled IHSs, but may also be state/territory-run IHS, Divisions of General Practice/Medicare Locals or other appropriate organisations. A description of the role and function of RTSHLTs in provided in chapter Error: Reference source not found.The integration of HLWs with the tackling smoking workforce was recommended by the Tobacco External Reference Group (see chapter Error: Reference source not found for details) and allows HLWs to access program supports that are provided through the Tackling Smoking (A1) measure, such as the National Coordinator for Tackling Indigenous Smoking, and material resources for health promotion. Integration is also intended to facilitate collegiality and mutual support, improved skill development, and create opportunities for a gender balance within teams, which may enable greater community engagement. The role of the HLWs within the RTSHLTs is to undertake health promotion with Aboriginal and Torres Strait Islander people to address lifestyle-related chronic disease risk factors. This may include promoting physical activity and healthy eating through planning and delivering community events and activities, identifying and supporting local role models to promote healthy lifestyles, and making referrals to Aboriginal health checks and other health services.HLWs are not required to be Aboriginal or Torres Strait Islander people, but should be able to demonstrate the capacity to work effectively with Aboriginal and Torres Strait Islander individuals and communities, and have a good understanding of relevant health and wellbeing issues. It is expected that HLWs will have, or be working towards, a Certificate III qualification in a relevant discipline. To this end, the host organisation is expected to provide for ongoing learning and development with a Registered Training Organisation. Approved Certificate III training courses for HLWs include Population Health, Aboriginal and/or Torres Strait Islander Primary Health Care, and fitness and recreation courses. As a result of the integration of the Tackling Smoking and HLW measures, HLWs also receive opportunities to network with colleagues from RTSHLTs across Australia.






Host organisations receive operational funding for HLWs in conjunction with funding received for the tackling smoking workers under the Tackling Smoking measure. Operational funding covers the costs of salaries, program administration and management, equipment, set up, training allocation, vehicles and travel/accommodation allowance. The total budget for the measure for the duration of the ICDP (from 2009-10 to 2012-13) is $37.53 million. More detail about delivery of the HLW measure, including the measure stakeholders and alignment with the National Indigenous Reform Agreement, is provided in chapter Error: Reference source not found along with information about the Tackling Smoking measure; reflecting the combined nature of these two measures. 6.2 Rationale and supporting evidence The HLW measure responds to high prevalence of lifestyle related risk factors among Aboriginal and Torres Strait Islander people, and the resulting health impacts including overweight and obesity and more broadly, chronic disease.144

In 2004-05, the NATSIHS indicated that 29 per cent of Aboriginal and Torres Strait Islander respondents (aged 18 years and over) were overweight and 31 per cent were obese.145 Lifestyle related risk factors that are common amongst Aboriginal and Torres Strait Islander populations (and are also some of the key contributors to the gap in life expectancy for Aboriginal and Torres Strait Islander people) are poor nutrition, being overweight and physical inactivity (12 per cent).146 Despite this, research suggests that many Aboriginal and Torres Strait Islander people have limited knowledge of risk factors and preventative strategies for chronic disease, and inaccurate perceptions about the impact of lifestyle behaviours on health outcomes.147

Evidence related to delivery of health promotion activities

Health promotion activities, for example targeting nutrition and physical activity, can contribute to reducing many lifestyle related health problems such as obesity, amongst Aboriginal and Torres Strait Islander populations. Research suggests that multi-component healthy lifestyle programs are one of the more effective approaches to addressing these chronic disease risk factors for Aboriginal and Torres Strait Islander people. There is evidence to suggest that effective programs incorporate a range of activities such as health promotion

144 Australian Institute of Health and Welfare 2011, The health and welfare of Australia’s Aboriginal and Torres Strait Islander people an overview, AIHW, Canberra.145 Australian Bureau of Statistics 2006, National Aboriginal and Torres Strait Islander Health Survey 2004–05, cat. no. 4715.0, ABS, Canberra.146 Vos T, Barker B, Begg S, Stanley L & Lopez AD 2009, ‘Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap’, International Journal of Epidemiology, vol. 38, pp. 470–477.147 Australian Institute of Health and Welfare 2011, Health risk factors, viewed October 2011.




http://www.aihw.gov.au/health-risk-factors-indigenous/



and community education148, screening, interventions and medical treatment.149 Multi-component programs have been shown to influence knowledge of health risk factors and their link to health problems, and lead to changes in health outcomes such as weight control.150 Based on available research, there are a range of critical determinants for success in the development and delivery of health promotion programs for Aboriginal and Torres Strait Islander people. These include: involving local communities in determining and directing their needs for

healthy lifestyle programs151,152 , however, there must be consideration of evidence based approaches while tailoring ‘what works’ to the needs of the community153;

community approval and involvement in program delivery, for example through Aboriginal community controlled IHSs, to ensure programs are accessed by community members154;

delivery of programs that are culturally appropriate or that link to culture, for example including promotion of traditional activities such as hunting and dancing155;

148 Coppell KJ, Tipene-Leach DC, Pahau HLR, Williams SM, Abel S, Iles M, Hindmarsh JH & Mann, JI 2009, ‘Two-year results from a community-wide diabetes prevention intervention in a high risk indigenous community: the Ngati and Healthy project’, Diabetes Research and Clinical Practice, vol. 85, no. 2, pp. 220-227.149 Gracey M, Bridge E, Martin D, Jones T, Spargo RM, Shephard M & Davis EA 2006, ‘An Aboriginal driven program to prevent, control and manage nutrition related “lifestyle” diseases including diabetes’, Asia Pacific Journal of Clinical Nutrition, vol. 15, no. 2, pp. 178-188.150 Coppell KJ, Tipene-Leach DC, Pahau HLR, Williams SM, Abel S, Iles M, Hindmarsh JH & Mann, JI 2009, ‘Two-year results from a community-wide diabetes prevention intervention in a high risk indigenous community: the Ngati and Healthy project’, Diabetes Research and Clinical Practice, vol. 85, no. 2, pp. 220-227.151 Jamieson S & Heron B 2009, ‘Evaluating the effectiveness of a healthy cooking class for Indigenous youth’, Aboriginal and Islander Health Worker Journal, vol. 33, no. 4, pp 6-9.152 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health, Sydney.153 Griew R 2008,The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.154 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health, Sydney.155 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.









multidisciplinary, cross sectoral and collaborative approaches to ensure programs are holistic and address social determinants of health156,157; and

secure and adequate resourcing for sustainability.158

6.3 The central causal pathway The outcomes which this measure aims to achieve should occur over the short, medium and long term and are influenced by factors both within and outside of the measure. The expected results that should occur as a result of the activities of this measure represent a ‘causal pathway’. The model below reflects KPMG’s interpretation of the central causal pathway that is implicit in the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved (which may be both within and external to the ICDP) and build upon each other over time (light text boxes).

Helping Indigenous Australians Reduce Their Risk of Chronic Disease

Increase in knowledge and understanding of lifestyle

related chronic disease risk factors

Improved uptake of healthy lifestyle choices

Change in attitudes towards making healthy

lifestyle choicesReduced chronic disease

risk factors

Recruitment, retention and capacity building of

the workforce

Activities are effectively

implemented and evidence based

Individual communities are receptive to

messages

Individual and community motivation

to change

Figure 6: HLW measure causal model. Source: KPMG. 6.4 Reach and timeframesThe potential reach159 of the HLW measure will be determined by a number of factors, most notably the number and distribution of the HLW workforce and the number of Aboriginal and Torres Strait Islander people who are exposed to and/or engage in activities provided as a result of the measure. In terms of workforce, it is intended that 57 host organisations will be funded across Australia under this measure with two HLWs within RTSHLTs by 2013. This totals 114 HLWs by 2013.

156 Griew R 2008,The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.157 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.158 Griew R 2008,The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.159 The term ‘reach’ in this Report refers to the potential and actual penetration of the measure’s impact on the intended target group.









No targets have been set for the number of Aboriginal and Torres Strait Islander people engaged by RTSHLTs. However it is expected that the level of consistency between the health promotion activities delivered, and the critical success factors identified in the evidence base (outlined above) will impact on the level of engagement/participation in the measure.In the early years (years 2 – 4), this measure is expected to result in participating community members having improved understanding of health risks and benefits associated with healthy lifestyle choices and of the resources available to support healthy lifestyle choices; increased utilisation of primary health care services; and strong, sustained participation in healthy lifestyle interventions. It is also expected to result in HLWs having the knowledge and skills to provide healthy lifestyle activities.In the medium term (greater than four years) at a systems level, the measure is expected to support a sustained increase in organisational capacity to provide healthy lifestyle activities. At a community level, the measure is expected to result in increased and sustainable community engagement in healthy lifestyle activities. As a result of healthy lifestyle choices being made among the Aboriginal and Torres Strait Islander population, the measure should lead to reduced incidence and prevalence of risk factors associated with chronic disease.6.5 Complementary activity A number of other initiatives have aims consistent with the HLW measure including around enhancing nutrition and exercise. Much activity in the public and preventative health space is also focused on tackling smoking. Refer to Appendix D for more information on Policy Maps which identify these complementary activities.Within the ICDP itself, other measures can also be expected to contribute to an increase in healthy lifestyle choices, most notably the Local Indigenous Community Campaigns to Promote Better Health (A3) measure and the Tackling Smoking (A1) measure. Measures which seek to enhance Aboriginal and Torres Strait Islander people’s access to primary health care160 may also contribute to a reduction in lifestyle-related chronic disease risk factors. The HLW measure is also related to the Workforce Support, Education and Training (C1) measure; as the orientation, training and education needs assessment for Aboriginal and Torres Strait Islander Outreach Workers provided under that measure, and for Healthy Lifestyle Workers under this HLW (A2) measure, was developed concurrently by the Aboriginal and Torres Strait Islander Health Registered Training Organisation National Network.Refer to Appendix C for more information on the key synergies between the different measures of the ICDP.

160 Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a), Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3)






6.6 Helping Indigenous Australians Reduce Their Risk of Chronic Disease data sources

Evaluation of this measure will be informed by a range of primary data sources such as: consultation with RTSHLTs, host organisations and community members; health workforce and organisational surveys; and review of program documentation. In year four (2012-13) a range of secondary data sources may provide information about whether a sustained change in the prevalence of chronic disease risk factors has occurred for Aboriginal and Torres Strait Islander people who are in contact with HLW (A2) measure activities. These may include: Australian Primary Care Collaboratives (APCC), Healthy for Life (H4L), Northern Territory Aboriginal Health Key Performance Indicator (NTAHKPI) and Queensland Aboriginal and Islander Health Council (QAIHC) Core Indicators data sources. Appendix E discusses these sources, including some of the challenges around access to these sources and their limitations. Also in year four, MBS data will inform on whether the utilisation of primary health care services by Aboriginal and Torres Strait Islander people, to support healthy lifestyle choices, has increased. MBS data will also be used annually to assess whether health checks have increased as a result of HLW (A2) measure activities. The Evaluation Framework161 identifies a number of indicators to measure the impact of the whole of Package, some of which are directly relevant to this measure. These are: Level of physical activity, reported in section 2.22 of the HPF. The proportion

of sedentary Aboriginal and Torres Strait Islander people aged 15 years and over was estimated at 47 per cent in 2004-2005.

Dietary habits, reported in section 2.23 of the HPF. In 2004-2005, the age standardised proportion of persons aged 12 years and over reporting no usual daily vegetable consumption was 5.3 per cent, a proportion that is seven times as high as that for the non-Aboriginal and Torres Strait Islander population.

Prevalence of overweight and obesity, as reported in section 2.26 of the HPF. In 2004-2005, 34 per cent of Aboriginal and Torres Strait Islander people were obese, when standardised for age.

Refer to Appendix F for further information about these indicators, including original sources. The evaluation will monitor and provide updates on these indicators as they become available.6.7 Year one progress Due to joint implementation, the activities undertaken to implement the HLW measure in 2009-10 are largely reflected in the description provided for the Tackling Smoking (A1) measure in chapter Error: Reference source not found above. 161 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.








In addition, in 2009-10, the education and training needs of the HLW workforce was the subject of a needs assessment commissioned by the department and delivered in November 2009 (coupled with a needs analysis for Aboriginal and Torres Strait Islander Outreach Workers under the Workforce Support, Education and Training (C1) measure, as noted above).162 The needs analysis was completed through consultation (surveys and phone interviews) with peak bodies and members of the Aboriginal and Torres Strait Islander Health Registered Training Organisation National Network. 20 funding agreements were put in place with host organisations in 2009-10. Funding was provided late in 2009-10 and therefore recruitment and activity commenced in the next financial year. The 2009-10 the actual expenditure by the department on the HLW measure was $1.6 million.Three performance indicators for this measure are included in the Commonwealth Implementation Plan:

Number of healthy lifestyle workers funded and trained. Number of healthy lifestyle sessions and activities conducted. Number of participants in healthy lifestyle sessions and activities.163

Given that recruitment commenced in 2010-11, progress against these indicators is not relevant for 2009-10.

162 Aboriginal and Torres Strait Islander Health Registered Training Organisation National Network 2009, An orientation, education and training needs analysis for the new and existing Aboriginal and Torres Strait Islander health workforce, Final Report, ATSIHRTONN, Adelaide.163 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.






7. Local Indigenous Community Campaigns to Promote Better Health

Local Indigenous Community Campaigns to Promote Better Health (A3) at a glanceICDP priority area: Tackling chronic disease risk factors.The issue being addressed: The rates of chronic risk factors among Aboriginal and Torres Strait Islander people are much higher than the rest of the Australian population, leading to higher rates of chronic disease and mortality. The ICDP solution: This measure involves development and delivery of targeted Local Community Campaigns (LCCs) to promote better health, and provision of resources to support the effective and sustainable delivery of LCCs.The supporting evidence: The design of this measure was guided by developmental research which recommended the delivery of local grass roots health campaigns.164 These campaigns should address barriers to adoption of healthy lifestyles and incorporate an Aboriginal and Torres Strait Islander understanding of health and wellbeing. The central causal pathway: The measure aims to assist Aboriginal and Torres Strait Islander community members to increase their healthy lifestyle choices. In order to achieve this outcome, the measure provides grants to allow organisations to develop locally appropriate campaigns aimed at making changes in the knowledge, attitudes and behaviours in relation to lifestyle choices Aboriginal and Torres Strait Islander individuals and communities. Reach: The potential and actual reach of the LCC measure will be determined by the number and distribution of the LCCs and the number of Aboriginal and Torres Strait Islander people who participate in or are exposed to the LCCs. Timeframes: In the shorter term (defined here as two to four years) the LCC measure is expected to improve the capacity of organisations and individual staff to provide information, activities and support to Aboriginal and Torres Strait Islander people relating to healthy lifestyle choices. It is expected that significant and sustained outcomes associated with a reduction in chronic disease risk factors will occur over a longer timeframe.

164 Note, this research was reportedly consistent with other Australian Government communications research that indicates a preference amongst Aboriginal and Torres Strait Islander Australians to hear messages locally from trusted intermediaries. Based on information provided by the Department of Health and Ageing.






Year one progress: In the baseline year (2009-10) the key activity within this measure was commissioning research to inform the measure’s design and implementation.The Local Indigenous Community Campaigns to Promote Better Health measure is subject to additional evaluation activities and deliverables. This chapter provides an overview of the design and progress of the measure in 2009-10, however, more detailed information was provided to the department in a separate Local Indigenous Community Campaigns to Promote Better Health Baseline Report which will not be made public. 7.1 Design of the Local Indigenous Community Campaigns to

Promote Better Health (A3) measure (also referred to as the LCC measure)

The LCC measure represents a series of locally generated and delivered health promotion initiatives that target Aboriginal and Torres Strait Islander people at risk of chronic disease, including those who have low engagement with health services. The objective of the LCC measure is to encourage Aboriginal and Torres Strait Islander communities to adopt sustainable healthy lifestyle choices including increased engagement with primary healthcare services. Delivery of the measure is broadly divided into two components, as follows: Local Community Campaigns grants projects, to be delivered by local

community organisations with the objective of promoting sustainable behavioural change around chronic disease prevention, healthy lifestyle choices and the benefits of accessing primary healthcare; and

a coordinated national communications and program support strategy comprised of:- ‘Healthy Community Day’ events to raise awareness of chronic disease,

healthy lifestyle choices and local primary healthcare services;- a website (‘Get Active, Eat Good Tucker, Live Longer!’)165 that is designed

to share information and stories about Indigenous chronic disease health promotion activities and events; and

- a Community Health Action Pack (the CHAP) to support Indigenous communities design and deliver health promotion activities including, but not restricted to, those taking part in the Local Community Campaigns program.

The Australian Government has committed approximately $21.3 million (excluding GST) to this measure over 2009-10 to 2012-13.

Research

In 2009, the department commissioned the Ipsos-Eureka Social Research Institute and Winangali Pty Ltd to develop a research report to inform the department of the best approach to delivering the LCC measure.166 The Ipsos-Eureka research recommended that to be effective, social marketing campaigns

165 Australian Government 2012, Live Longer (website), viewed April 2012.86



http://livelonger.health.gov.au/



need to target numerous barriers to change in Aboriginal and Torres Strait Islander communities, including: limited access to and understanding of health services; low levels of health literacy; fatalistic beliefs about the inevitability of experiencing chronic disease; low levels of proactive attitudes towards chronic disease prevention; socio-cultural factors that reinforce potentially harmful behaviours; restricted access and negative attitudes to exercise options; and poor diet due to the cost and availability of healthy foods in remote areas,

and low nutritional and cooking knowledge.The Ipsos-Eureka research also highlighted differences in the way Aboriginal and Torres Strait Islander people view health, wellbeing, self and time compared to non-Aboriginal and Torres Strait Islander people, and how this impacts service and program delivery.167 The key findings were: The concept of individual health is of low relevance with the role of family and

the community more valued by Aboriginal and Torres Strait Islander people. This can take precedence over any medical advice or preventative health messages if they make the individual feel socially isolated.

Given the emphasis on family and the community, health messages to Aboriginal and Torres Strait Islander people are more effective if they focus on the family or community’s benefit rather than the individual.

Communication approaches should adopt a whole-of-community approach and health messages are better received if they are developed locally and delivered in a style containing local and familiar elements. Communication is also more effective if delivered by familiar faces in a form that accommodates the linguistic needs of the local community.

To effectively reach the target audience, the Ipsos-Eureka research report made several key recommendations for the department to ensure the success of the LCC measure and associated social marketing campaigns. These recommendations were to168: increase awareness of what diseases are chronic; increase awareness of the links between risk factors and chronic disease;166 Ipsos-Eureka Social Research Institute and Winangali Pty 2010, Developmental Research to inform the Local Aboriginal and Torres Strait Islander Community Campaigns to Promote Better Health, Department of Health and Ageing, Canberra.167 Ipsos-Eureka Social Research Institute and Winangali Pty 2009, Local Aboriginal and Torres Strait Islander Community Campaigns to Promote Better Health – A Review of the Current Literature, Department of Health and Ageing, Canberra.168 Ipsos-Eureka Social Research Institute and Winangali Pty 2010, Developmental Research to inform the Local Aboriginal and Torres Strait Islander Community Campaigns to Promote Better Health, Department of Health and Ageing, Canberra.






link health behaviours to positive social outcomes in the forms of benefits for children, family or community;

avoid negative themes; build on past campaigns where they were designed around emotive

messages with a family or community focus; use simple, clear and jargon free language and, where possible, a narrative

approach; use familiar or local Aboriginal and Torres Strait Islander people for the

campaigns; apply Aboriginal English; use visual themes applying Aboriginal and Torres Strait Islander imagery and

art work; use a range of communication channels including television, radio, internet

and billboard/poster advertising; and tailor messages to audience segments by life-stage, exposure to risk of

developing chronic disease, gender and geographic location, with the priority target group for communications being young people of school-age (approximately 5-15 years of age).

Additionally, it was recommended that LCCs would be strengthened by: promoting local preventative health services; promoting amongst local health professionals the dual role of primary care

being aimed at treatment and prevention of chronic disease; promoting amongst health professionals and the wider community the range

of Medicare items available that target Aboriginal and Torres Strait Islander audiences; and

addressing issues arising from physical distances to health services.Consequently, the department decided on a local rather than national campaign model. The LCC measure responds to the need to improve understanding amongst Aboriginal and Torres Strait Islander people of the risk factors involved in chronic disease and to know which lifestyle behaviours and health services can help prevent or better manage chronic disease.

Local Community Campaigns (LCC) grants

The Local Community Campaigns grants represent the centrepiece of the measure, and are intended to fund grassroots health campaigns that respond to local community needs relating to chronic disease. It is intended that LCCs promote the use of community resources and health services, and provide education and practical instruction to communities about the risk factors of chronic disease and how to reduce them.






The Australian Government is providing approximately $15 million (GST exclusive) in funding for LCCs from 2011-13 through two competitive rounds of grant funding; one targeted and one open. A wide range of organisations are funded to deliver LCCs including community controlled and mainstream health services, educational institutions, public media broadcasters, media production organisations and charitable or community support organisations. Funded campaigns target diverse audiences with a range of health messages delivered through different means including: physical activity sessions; practical nutritional instruction; forums and workshops; and traditional Aboriginal and Torres Strait Islander activities.

Stakeholders

The stakeholders of this measure include internal and external parties at local/ community, regional, jurisdictional and national levels. Table 7 below provides an overview of the key stakeholder groups and their roles in relation to the LCC measure since its implementation.






Table 7: Key stakeholders and roles in the LCC (A3) measure.169

Stakeholder type Stakeholder Role in the LCC (A3) measure

Department stakeholders


Provide oversight of the measure, including commissioning research and managing the grant application and selection processDirect management of some grant recipients and management of non-grant activities

Department stakeholders

Department state/territory offices

Manage contracts with the majority of grant recipients

Workforce stakeholders


Potential and actual grant recipients


Divisions of General Practice/Medicare Locals



Other community organisations



Aboriginal and Torres Strait Islander community members

Target audience for, and participants in, LCCs

Adherence to the service delivery principles

Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).170 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the LCC measure.Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. LCCs have a strong focus on addressing the risk factors for chronic disease; a

cornerstone of the COAG NIRA, while delivering messages through activities that are consistent with local community needs.

169 Based on information provided by the Department of Health and Ageing. 170 Council of Australian Governments 2011, National Indigenous Reform Agreement (Closing the Gap), Schedule D, viewed September 2012.








Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. The LCC measure developmental research conducted by Ipsos SRI occurred in

partnership with the Aboriginal and Torres Strait Islander company Winangali Pty Ltd and included extensive consultation with Aboriginal and Torres Strait Islander stakeholders.

A significant engagement process including with Aboriginal and Torres Strait Islander stakeholders was undertaken during the development of the grants guidelines and to encourage applications for the grants rounds.

The majority of LCCs are being delivered by organisations with a strong connection to target Aboriginal and Torres Strait Islander communities.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The LCC measure is funded over four years from 2009-10 to 2012-13. Many

LCCs include components around infrastructure improvement, community member training and the development of educational resources to promote the continuation of activities and messages beyond the life of the campaign.

The development and distribution of the CHAP (a health promotion resource) and the delivery of a workshop with RTSHLTs to learn about this resource is intended to extend the impact of the measure.

The sustainability of the program will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. LCCs are being delivered across Australia in a broad range of urban, regional

and remote communities, with a focus on areas with high Aboriginal and Torres Strait Islander populations.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. This measure involves integration and linkages between the department and

the Indigenous Communications Coordination Group and the Department of Finance and Deregulation’s Communications Advice Branch.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. LCC grant recipients are subject to reporting and communication

requirements with the department including the delivery of a progress report against agreed campaign actions.

The LCC measure is included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation. An additional level of monitoring is also occurring through the LCC measure Evaluation.






7.2 Rationale and supporting evidenceIt is widely accepted that the prevalence of risk factors for chronic disease, including physical inactivity, alcohol and substance misuse, poor diet, obesity and diabetes, is excessively high in Aboriginal and Torres Strait Islander communities.171 The LCC measure responds to this by delivering locally generated and relevant health promotion initiatives to Aboriginal and Torres Strait Islander people, with the aim of encouraging and supporting them to adopt sustainable healthy lifestyle choices.

Summary of evidence for LCCs

Research conducted by Ipsos SRI in 2009 identified numerous barriers to the uptake of health promotion activities and healthy lifestyle messages in Aboriginal and Torres Strait Islander communities. This research also identified important differences in the way Aboriginal and Torres Strait Islander people view health and wellbeing compared to non-Indigenous people.172 The research recommended a grassroots and tailored approach to delivering health messages to Aboriginal and Torres Strait Islander people. This recommendation guided the department to implement a local, grants based program, rather than national social marketing model for the LCC measure. 7.3 The central causal pathway The outcomes which this measure aims to achieve should occur over the short, medium and long term and are influenced by factors within and outside of the measure. The expected changes that should occur in promoting healthy lifestyle choices as a result of the activities of this measure represent a ‘causal pathway’.The diagram below reflects KPMG’s interpretation of the central causal pathway that is inferred from the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (represented by dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other over time (represented b light text boxes).

171 Australian Bureau of Statistics 2009, The health and welfare of Australia’s Aboriginal and Torres Strait Islander people, cat. no. 4704.0, ABS, Canberra.172 Ipsos-Eureka Social Research Institute and Winangali Pty 2010,Developmental Research to inform the Local Indigenous Community Campaigns to Promote Better Health, Department of Health and Ageing, Canberra.






Local Indigenous Community Campaigns to

Promote Better Health

Increase in knowledge and understanding of lifestyle

related chronic disease risk factors

Improved uptake of healthy lifestyle choices

Change in attitudes towards making healthy

lifestyle choicesReduced chronic disease

risk factors

Increase in community mobilisation

Projects are effectively implemented and evidence based

Individuals and communities engage

with and participate in LCCs

Figure 7: LCC causal model. Source: KPMG. 7.4 Reach and timeframes The potential reach173 of the LCC measure will be determined by the number and distribution of the grants and the number of Aboriginal and Torres Strait Islander people who participate in or are exposed to the campaigns. This reach may be extended by the supporting activities and resources. 35 organisations have been funded to deliver a total of 38 Local Community Campaigns through the first targeted grants round. The expected early results (years 2-4) include: communities have an enhanced understanding of health risks and benefits

associated with lifestyle choices; participants increasingly make more healthy lifestyle choices; participants have increased awareness of the importance of accessing

primary health care; communities have enhanced capacity to initiate local campaigns; and communities have sustained participation in LCC activities.Medium term (longer than 4 years) results expected to be achieved include: participants sustain healthy lifestyle choices; participants increase their use of primary health care services; participants have a reduction in the incidence and prevalence of risk factors

associated with chronic disease; and communities have increased and sustained capacity to undertake community

level campaigns.7.5 Complementary activity Various national, state and territory funded activities for both mainstream and Aboriginal and Torres Strait Islander populations are also aimed at addressing chronic disease risk factors. Thus any changes in attitudes and behaviours around healthy lifestyle choices will come about as a result of the combined

173 The term ‘reach’ in this Report refers to the potential and actual penetration of the measure’s impact on the intended target group.






efforts of various programs. Refer to Appendix D for more information on Policy Maps which identify these complementary activities.Within the ICDP itself, other measures can also be expected to contribute to an increase in healthy lifestyle choices, most notably the HLW (A2) measure and the Tackling Smoking (A1) measure. Measures which seek to enhance Aboriginal and Torres Strait Islander people’s access to primary health care174 may also contribute to similar outcomes. Refer to Appendix C for more information on the key synergies between the different measures of the ICDP.7.6 Local Community Campaigns to Promote Better Health data

sources Evaluation of the LCC measure will be informed by a range of primary data sources including: consultation with grant recipients, local communities and other LCC stakeholders; development of LCC measure case studies; and analysis of program documentation.Analysis of website activity data and CHAP feedback surveys (2010-11 and 2012-13 data) will inform on the extent to which grant recipients have used the support resources available through the measure, and how valuable these resources have been. MBS data on 715 health checks will also be analysed in year four to understand whether LCC participants are more likely to access health care to manage their chronic diseases and risk factors.Grant recipients are required to report on high-level data including the achievement of milestones, participation numbers and participant feedback on the organisation and conduct of activities. However, only a handful of funded organisations have stated an intention to collect data informing the impact of LCC activities on participants’ health, knowledge and lifestyles. As such it is unclear how the evaluation will be informed of the success of the LCC measure in achieving many of the intended early and medium term results outlined in the Evaluation Framework. The Evaluation Framework175 identifies a number of indicators to measure the impact of the whole of Package which are directly relevant to this measure. These are: Level of physical activity, reported in section 2.22 of the Health Performance

Framework (HPF). The proportion of sedentary Aboriginal and Torres Strait Islander people aged 15 years and over was 47 per cent in 2004-2005.

Dietary habits, reported in section 2.23 of the HPF. In 2004-2005, the age standardised proportion of Aboriginal and Torres Strait Islander persons aged

174 Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a), Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3)175 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.








12 years and over reporting no usual daily vegetable consumption was 5.3 per cent.

Prevalence of overweight and obesity, as reported in section 2.26 of the HPF. In 2004-2005, 34 per cent of Aboriginal and Torres Strait Islander people were obese, when standardized for age.

Refer to Appendix F for further information about these indicators, including original sources. The evaluation will monitor and provide updates on these indicators as they become available.7.7 Year one progress Activity in 2009-10 for the LCC measure largely consisted of commissioning and overseeing the research undertaken by Ipsos SRI and Winangali Pty Ltd. Three performance indicators for this measure are included in the Commonwealth Implementation Plan; however these are no longer relevant given the shift to a grants based program.176

176 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.






8. Subsidising PBS Medicine Co-payments Subsidising PBS Medicines Co-payments (B1) measure at a glanceICDP priority area: Priority health care services that deliver.The issue being addressed: Despite a higher burden of chronic disease, PBS expenditure for Aboriginal and Torres Strait Islander people is about half that of non-Aboriginal and Torres Strait Islander people. Access to medication is an important aspect of chronic disease management, and the cost of medicines has been identified as a significant barrier to access for Aboriginal and Torres Strait Islander people.177

The ICDP solution: This measure provides financial subsidy for the co-payments for PBS medications prescribed by eligible practices for eligible Aboriginal and Torres Strait Islander patients and dispensed by approved suppliers. As a result of the subsidy, patients have access to PBS medicines at the PBS concessional rate or free of charge (if they are already eligible for a concessional rate). The supporting evidence: International evidence indicates that reduction in financial barriers to prescribed medications will increase their use amongst patients for whom cost is a barrier. In Australia, two existing programs include a component that subsidises or removes the PBS copayment for eligible Aboriginal and Torres Strait Islander people. While these programs have additional supportive components, the reduced financial cost has been shown to be a key contributor to their success in improving utilisation of prescribed PBS medications. The central causal pathway: The PBS Co-payment measure aims to improve management of chronic disease by removing or reducing the financial barriers to the regular use of prescribed medicines. Reach: The reach of the measure is determined by the number and location of participating practices and pharmacies, and the number of registered Aboriginal and Torres Strait Islander patients who receive and use the medicines as a result of the reduced or removed PBS co-payment.Timeframes: Within two to four years, participating patients are expected to increase their utilisation of PBS medicines for the management of chronic disease. Within four years, participating patients should experience clinical improvements. These effects should be increased and sustained beyond this timeframe. Year one progress: In 2009-10 the key activities that occurred within this measure included the establishment of a Technical Reference Group to oversee implementation, development of prescriber and pharmacy software to accommodate the Closing the Gap (CtG) scripts178, and provision of information to key stakeholders.

177 Department of Health and Ageing 2010, Subsidising PBS medicine co-payments (website), viewed September 2012.




http://www.health.gov.au/internet/ctg/publishing.nsf/content/subsidising-pbs-medicine-co-payments



8.1 Design of the Subsidising PBS Medicine Co-payments (B1) measure (also referred to as the PBS Co-payment measure)

This measure provides reimbursement to approved suppliers (primarily pharmacists) in order to allow Aboriginal and Torres Strait Islander patient access to medicines at the Pharmaceutical Benefits Scheme (PBS) concessional rate (if the patient does not have a concession card) or free of charge to the patient (if the patient has a concession card).179 Subsidised medications (CtG scripts) are prescribed by General Practitioners (GPs) at participating general practices or Indigenous health services (IHSs) located in urban and rural locations, and are dispensed through approved suppliers. Medical specialists can annotate CtG scripts for registered patients referred to them by participating GPs. Nurse Practitioners cannot annotate CtG scripts. In order to participate in the PBS Co-payment (B1) measure, mainstream general practices must be registered for the Practice Incentives Program (PIP) Indigenous Health Incentive.180 Indigenous health services located in urban and rural locations are eligible to participate either through the PIP Indigenous Health, or through application to the department for the PBS co-payment under ‘special arrangements’ allowed by section 100 of the National Health Act 1953 (Cth) (the Act). Patients must provide informed consent to be registered by their practice, and registration is a one-time application. The patient registration for the PBS Co-payment and PIP Indigenous Health Incentive is done via the same paper based form, although there is a separate section for each measure. Patients eligible for this measure are Aboriginal and Torres Strait Islander patients, including children, who have an existing chronic disease or are ‘at risk’ of chronic disease.181

In addition to these eligibility factors, the PBS Co-payment measure requires that the GP determine that the patient: a) would experience setbacks in the prevention or ongoing management of chronic disease if the person did not take the prescribed medicine; and b) is unlikely to adhere to his/her medicines regimen without assistance through the measure.182

GPs must annotate the patient’s PBS prescription as ‘CtG’ to enable patients to receive their PBS medicines free or at the reduced cost. The CtG annotation may be electronic (through use of an updated version of prescription writing software

178 The scripts which have been annotated to allow access to the co-payment subsidy are commonly referred to as ‘CtG scripts’. The measure is sometimes referred to as the CtG scripts measure by providers.179 The relevant co-payment thresholds during the baseline period were $32-90 for general patients and $5-30 for concessional patients from July to December 2009, then $33-30 and $5-40, respectively, from January to June 2010.180 Through the Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a) measure. 181 Note that this patient eligibility is broader than that for the PIP Indigenous Health Incentive (which is limited to patients aged over 15 with an existing chronic disease).182 Commonwealth of Australia 2011, PBS Co-payment measure Pharmacy Staff Resource Booklet, Commonwealth of Australia, Canberra.






that supports the Closing the Gap annotation), or the GPs may handwrite “CtG” on the top right hand side of the script. Registered patients are able to fill prescriptions at approved suppliers. This includes all community pharmacists approved under section 90 of the National Health Act 1953 (Cth) (the Act), dispensing doctors approved under section 92 of the Act, and private hospital authorities approved under section 94 of the Act.183 Approved suppliers do not need to register in order to participate in the PBS Co-payment measure. Pharmacy software has been updated with CtG functionality to support the processing of CtG scripts. Approved suppliers (pharmacists and others) are reimbursed in full for the co-payment amount the patient no longer pays. Approved suppliers are reimbursed both for the standard PBS medicine and for the proportion of the normal PBS co-payment that has not been paid by the patient. This is a seamless reimbursement process. The payments are made by the Department of Human Services (Medicare Australia) to approved suppliers as per the normal payment process/schedule, and will be calculated automatically.The ICDP PBS Co-payment measure is designed to operate where there is infrastructure support to dispense PBS medicines, primarily in urban and regional Australia. The Special Supply Arrangements to Remote Area Aboriginal Health Services program (which also operates through Section 100 of the National Health Act 1953) is a non-ICDP program which operates in remote and very remote areas. This program is known as the S100 RAAHS Supply program. Together these two programs support Aboriginal and Torres Strait Islander people to access general schedule PBS medicines.

Program support

There are a number of program supports which have facilitated and enhanced the implementation of the PBS Co-payment measure. These include software projects, legislation, and promotional materials and avenues. The measure includes the development of software products to allow prescribers and pharmacies to process the co-payment. These software updates have been developed with the Medical Software Industry Association and are provided to users free of charge.A range of promotional materials were developed for stakeholders, including the Pharmacy Staff Resource Booklet184, one copy of which has been distributed to each Section 90 registered pharmacy in Australia. Factsheets have been, and continue to be, provided to mainstream primary health care practices and IHS sector services, and presentations have been, and continue to be, delivered to key stakeholder organisations. Email and phone hotlines are available to answer enquiries from stakeholders including the public.185

183 Department of Health and Ageing 2010, Pharmacy Staff Resource Booklet, Commonwealth of Australia, Canberra, viewed April 2012.184 Department of Health and Ageing 2010, Pharmacy Staff Resource Booklet, Commonwealth of Australia, Canberra, viewed April 2012.




http://www.health.gov.au/internet/ctg/publishing.nsf/Content/pharmacy-staff-resource-booklet-measure-booklet#4

http://www.health.gov.au/internet/ctg/publishing.nsf/Content/pharmacy-staff-resource-booklet-measure-booklet#4



The PBS Co-payment measure has a budget of $88.7 million over the first four years of the ICDP implementation. This encompasses the budget for the co-payment subsidy itself as well as program supports. This budget represents an estimate of the likely cost of the measure; actual cost will depend on the volume of Closing the Gap (CtG) annotated prescriptions being processed.

Stakeholders

Table 8 below provides an overview of the key stakeholder groups and their roles in relation to the PBS Co-payment measure since its implementation.Table 8: Key stakeholders and roles.186

Stakeholder Role in PBS Co-payment measureDepartment Central Office

Manage funding agreements with software vendors; coordinate national monitoring and reporting

Department state / territory offices No direct role

Technical Reference Group

Provide the department with technical advice on the measure

Mainstream General Practices

Apply to participate in PBS Co-payment measure (through the PIP Indigenous Health Incentive or special arrangements)Adopt prescribing software for CtG annotation, if desiredPrescribe medication through CtG annotation


Apply to participate in PBS Co-payment measure (through the PIP Indigenous Health Incentive or special arrangements)Adopt prescribing software for CtG annotation, if desiredPrescribe medication through CtG annotation

Approved suppliers Dispense medication prescribed through CtG annotationCollect reimbursement from government for co-payment

Medical software providers

Modify software to accommodate co-payment in PBS prescribing and dispensing

185 Information hotline is accessible through email ([email protected]) and telephone (02 6289 2409).186 Based on information provided by the Department of Health and Ageing.






Stakeholder Role in PBS Co-payment measureDepartment of Human Services (Medicare Australia)

Calculate and make payments to approved suppliers as per the normal PBS payment process/scheduleModify the Medicare Australia IT system to capture PBS Co-payment (B1) measure dispensing and co-payment reimbursement data

Patients Consent to participate in the measure, through primary health care practiceSubmit annotated script to approved supplier to receive subsidised medication

A Technical Reference Group (TRG) provides the department with technical advice on the PBS Co-payment (B1) measure, specifically: administrative requirements for prescribers and community pharmacists; software requirements for prescription writing and dispensing; culturally appropriate implementation; effective communication and education strategies; and evaluation strategies.The TRG consisted of representation from the following key stakeholder groups: Pharmacy Guild of Australia; National Aboriginal Community Controlled Health Organisation; Pharmaceutical Society of Australia; Medical Software Industry Association; Australian Indigenous Doctors Association; Royal Australian College of General Practitioners; and Australian General Practice Network.


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).187 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the PBS Co-payment. Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The PBS Co-payment (B1) measure supports the core aims and targets of

Closing the Gap given its focus on chronic disease management by reducing

187 Council of Australian Governments 2011, National Indigenous Reform Agreement (Closing the Gap), Schedule D, viewed September 2012.








financial barriers to accessing needed medicines, which is expected to result in improved compliance with medicine use.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. The Technical Reference Group developed to inform this measure includes

representation from NACCHO and Australian Indigenous Doctors AssociationSustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The PBS Co-payment (B1) measure is funded over the first four years – 2009-

10 to 2012-13. The budget of the measure has the flexibility to expand to meet increasing demand for CtG scripts. The sustainability of the measure will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. IHSs and mainstream GPs in urban, regional and remote areas are eligible to

participate in the PBS Co-payment, either through participation in the PIP Indigenous Health Incentive, or through direct application under the ‘special arrangements’ allowed by legislation.

The introduction of ‘special arrangements’ for non-PIP registered IHSs has further extended the reach of the PBS Co-payment (B1) measure.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. The Department of Human Services (Medicare Australia) provides PBS Co-

payment (B1) measure information and data on a monthly basis by to OATSIH and the department STOs.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. The PBS Co-payment (B1) measure is included in two ICDP evaluation projects

– the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

The PBS Co-payment (B1) measure includes regular reporting and communication between the Department of Human Services (DHS – now includes Medicare Australia) and the department.

8.2 Rationale and supporting evidenceWhile there is clear evidence that Aboriginal and Torres Strait Islander people are more likely to experience ill-health, including chronic disease, PBS spending per Aboriginal and Torres Strait Islander person has been estimated to be around half of what is spent for a non-Aboriginal and Torres Strait Islander person.188 In

188 Australian Institute of Health and Welfare 2008, ‘Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004-05’, Health and welfare expenditure series no. 33, cat. no. HWE 40, Australian Institute of Health and Welfare, Canberra.






this section the link between financial barriers and appropriate use of medicines is explored, as is the evidence relating to whether addressing financial barriers will improve use of medicines. The relevance of the supporting evidence to the PBS Co-payment (B1) measure is also considered. This section assumes that there is a positive relationship between adherence to prescribed medications and health outcomes, and that Aboriginal and Torres Strait Islander people are likely to experience financial disadvantage.189

Evidence related to the link between financial status and use of medicines

One multinational study, which examined management of diabetes and associated cardiovascular risks, found that insurance status in countries without universal health care schemes (which in turn determines price of medications), was associated with control of diabetes.190 Another study that considered adherence to medications by employees in a health insurance plan, by co-payment status (i.e., employees with small, moderate or high co-payments under their health insurance plan) found an association between co-payments and adherence in diabetes medications191 – i.e., the lower the co-payment amount, the more likely employees would adhere to their medication requirements. A systematic review conducted in 2004 found that there was a consistent relationship between the use of a co-payment (cost sharing) policy and adherence to medications in vulnerable populations.192 A study on the costs of medications for people with chronic conditions, found that patients who reach the safety net193 within the first nine months of the year experience significant monthly costs of medications. For people with low incomes, including those who do not qualify for a concession card, this cost can be a barrier to the use of medications.194

These studies demonstrate that financial factors, including the availability of co-payments, represent one of a number of factors that influence compliance with (adherence to) medications for long term use. Other factors that influence compliance include access to primary care, health literacy, geographic/physical

189 Steering Committee for the review of government service provision 2007, Overcoming indigenous disadvantage: key indicators 2007, Productivity Commission, Canberra.190 Gakidou, E, Mallinger, L, Abbott-Klafter, J, Guerrero, R, Villalpando, S, Ridaura, RL, et al. 2011, ‘Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination survey’, Bulletin of the World Health Organization, vol. 89, no. 3, pp. 172-83.191 Colombi AM, Yu-Isenberg K, Priest JJ 2008, ‘The effects of health plan co-payments on adherence to oral diabetes medication and health resource utilization’, Occup Environ Med., 2008 May, vol. 50, no. 5, pp.535-41.192 Lexchin J, Grootendorst P 2004, ‘Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: a systematic review of the evidence’, Int J Health Serv., vol. 34, no. 1, pp. 101-22.193 The safety net reduces or removes the copayment when patients or households reach an annual medicine utilisation threshold. The aim of the safety net is to further reduce costs to patients with high levels of utilisation.194 B. Pekarsky and the Consumer’s Health Forum of Australia 1997, Cost of chronic illness and quality use of medicine.






access to a pharmacy and communication between prescribers and patients.195 Research indicates that financial barriers, along with other factors such as ‘shame’ in filling prescription and taking medicine, high mobility and low health literacy, have a considerable influence on Aboriginal and Torres Strait Islander people’s access to medicines.196,197 Finally, almost all of these studies and the associated literature also note that purchase of necessary medicines does not necessarily result in quality use of these medicines.

Evidence that addressing financial barriers will improve use of medicines

A small number of studies have identified modest, usually short term improvements in medication compliance with the removal of a co-payment in the absence of other program elements (such as Quality Use of Medicine components). One study found that a reduction in co-payments resulted in a modest increase in adherence to medicines in the short term.198 Another study, which compared adherence to medications for long term use199 across patients who had differential co-payments, found that patients with no co-payments had better adherence in the short and long term. Even small co-payments and small changes to co-payments were found to impact on adherence.200 A Cochrane review of the effectiveness of strategies to improve adherence to medications, found that there was little evidence of sustained impact resulting from these strategies overall.201 However, the review did not separate out the impact of reduction in financial barriers and other factors such as education. Another study identified overall improved adherence to medications associated with increased contribution to the costs of medicines by an insurer, or a cap on expenses for the patient, within the context of an existing chronic disease management program.202

Two programs which intended to improve access to medications by Aboriginal and Torres Strait Islander people existed prior to the implementation of the PBS

195 Gellad WF, Grenard JL, Marcum ZA 2011, ‘A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity’, Am J Geriatr Pharmacother, vol. 9, no. 1, pp. 11-23.196 Hayman, N 2011, ‘Improving Aboriginal and Torres Strait Islander people’s access to the Pharmaceutical Benefits Scheme’, Australian Prescriber, vol. 34, no. 2, pp. 38-40.197 Couzos S, Sheedy V & Thiele DD 2011, ‘Improving Aboriginal and Torres Strait Islander people’s access to medicines – the QUMAX program’, Medical Journal of Australia, vol. 195, no. 2, pp. 62-63.198 Maciejewski ML, Farley JF, Parker J, Wansink D 2010, ‘Copayment reductions generate greater medication adherence in targeted patients’, Health Aff (Millwood), vol. 29, no. 11, pp. 2002-8.199 Including: cardiovascular, diabetes and lipid lowering medications200 Maciejewski ML, Bryson CL, Perkins M, Blough DK, Cunningham FE, Fortney JC, Krein SL, Stroupe KT, Sharp ND, Liu CF 2010, ‘Increasing copayments and adherence to diabetes, hypertension, and hyperlipidemic medications’, Am J Manag Care, vol. 16, no. 1, pp. 20-34.201 Haynes RB, Ackloo E, Sahota N, McDonald HP, & Yao X 2008, ‘Interventions for enhancing medication adherence’, Cochrane Database Syst. Rev., April 16(2).202 Chernew M et al. 2008, ‘Impact of decreasing copayments on medication adherence within a disease management environment’, Health Affairs, vol. 27, no.1.






Co-payment (B1) measure: S100 RAAHS Supply program and Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander Peoples (QUMAX). These two programs have been reviewed and evaluated in a number of studies, which have shown positive outcomes including improved access to PBS medicines, improved medication compliance and improved health outcomes.203 204 However, these programs both involve components other than reduction in cost to patients, including physical supply of medications in areas where it was previously limited (S100 RAAHS Supply program) and Quality Use of Medicine training and resources (QUMAX). These programs are also intended to have a more specific population focus (smaller reach) compared to the PBS Co-payment (B1) measure.

Relevance of the supporting evidence to the PBS Co-payment (B1) measure

Based on the evidence presented above, there appears to be an association between income and adherence to medication, particularly medications for long-term use such as those necessary for treatment of chronic disease. There is also some evidence that reducing the cost to the patient (i.e., the financial barrier) may improve adherence to medication regimes, at least in the short term.However, other factors are also likely to contribute to medications compliance, and there are few studies that separately analyse the contribution made by financial barriers, partly because factors such as income and financial barriers are closely linked to other likely contributors such as access to primary health care and health literacy. Existing programs designed to improve access to and use of medications by Aboriginal and Torres Strait Islander people (S100 RAAHS Supply program and QUMAX) have reported positive impacts. However, they include a broader range of components, compared to the PBS Co-payment (B1) measure. Other components of the ICDP (such as PIP Indigenous Health Incentive, ATSIOWs or CCSS) may provide similar supports for some patients. Overall the rationale for the measure (reducing financial barriers for all Aboriginal and Torres Strait Islander patients with or at risk of chronic conditions) is supported by the evidence; however the likelihood of achieving longer term impact is unclear. 8.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in increasing Aboriginal and Torres Strait Islander access to PBS medicines as a result of the activities of this measure represent a ‘causal pathway’.

203 Urbis 2011, Evaluation of the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander Peoples (QUMAX) Program, Department of Health and Ageing, Canberra. 204 Kelaher M, Dunt D, Taylor-Thompson D, Harrison N, O’Donaghue L, Barnes T & Anderson I 2006, ‘Improving access to medicines among clients of remote area Aboriginal and Torres Strait Islander Health Services’, Australian and New Zealand Journal of Public Health, vol. 30, no. 2, pp. 177-183.






The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Approved suppliers participate

Patients have willingness and

support to adhere to medicines regimen

Aboriginal and Torres Strait

Islander patients participate

Prescribed medicines are

required for chronic disease

management

PBS Co-payment Reduced financial barrier

for purchase of pharmaceuticals

Improvement in Aboriginal and Torres Strait Islander

people’s chronic conditions

Increase in patients’ use of medicines for chronic disease management

Primary health care practices are

registered in PIP Indigenous Health

Incentive

Benefits outweigh administrative cost to primary health

care practices

Figure 8: PBS Co-payment measure causal model. Source: KPMG.8.4 Reach and timeframesThe potential reach205 of the measure will be determined by factors including the number and location of participating prescribers and pharmacies, and the number of registered Aboriginal and Torres Strait Islander patients who receive and use medicines as a result of the initiative.As an early result (years two to four) of the PBS Co-payment (B1) measure, participating Aboriginal and Torres Strait Islander people will have reduced financial barriers to accessing pharmaceuticals, and are expected to thus be able to use medicines in accordance with their care plans for the prevention or management of chronic disease.Over the longer term, the PBS Co-payment (B1) measure is expected to contribute to sustained improvements in relevant clinical indicators chronic disease among participating patients.8.5 Complementary activityWithin the ICDP itself, the PBS Co-payment (B1) measure is most closely related to the PIP Indigenous Health Incentive (B3a) measure. Mainstream general practices and IHSs must be registered for the PIP Indigenous Health Incentive to be able to prescribe within the PBS Co-payment measure, unless they have applied for and been granted approval under special arrangements put in place by the department. These special arrangements may be particularly important in areas where there are no practices registered for the PIP Indigenous Health Incentive. The PIP Indigenous Health Incentive and PBS Co-payment are linked at the patient level because registration is through one form (with separate sections for each measure).206 205 The term ‘reach’ in this Report refers to the potential and actual penetration of the measure’s impact on the intended target group.206 As noted elsewhere in this report the patient eligibility criteria for the PBS Co-payment measure are broader than the criteria for participation in PIP Indigenous Health Incentive.






Workers employed under other ICDP measures such as Indigenous Health Project Officers (IHPOs) and Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs) can influence uptake of the PBS co-payment through promotions of this measure to primary health care practices and patients. ICDP workers also promote the utilisation of primary health care services. Increasing access to primary health care services is likely to result in higher prescribing rates generally, including higher uptake of the PBS Co-payment.Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. Beyond the ICDP, the PBS Co-payment (B1) measure replaces the PBS Co-payment waiver component of the trial QUMAX program, the expiry date of which was extended to coincide with the 1 July 2010 implementation of the PBS Co-payment (B1) measure. A revised QUMAX program, focusing on Quality Use of Medicines (QUM) outcomes has been continued under the Fifth Community Pharmacy Agreement until 30 June 2015. The ICDP PBS Co-payment (B1) measure is designed to operate where there is pharmacy infrastructure in place to support PBS dispensing. In remote areas where pharmacy infrastructure is unavailable the non-ICDP S100 RAAHS Supply program operates. 8.6 PBS Co-payment data sourcesEvaluation of this measure will be informed by analysis of secondary data sources including PBS and PIP Indigenous Health Incentive data, a review of program documentation, organisational and health workforce surveys, consultation with mainstream and IHS providers, pharmacists, software vendors, community members and other relevant stakeholders. Appendix E discusses the secondary data sources in detail including limitations, and identifies other potential data sources for this measure. 8.7 Year one progress Although prescribing and dispensing scripts under the PBS Co-payment (B1) measure did not commence in 2009-10, significant activity was undertaken to prepare for full implementation. This activity included consultation, technical preparations and promotion of the measure. From 20 June 2009, an independent Technical Reference Group was established to oversee the implementation of the PBS Co-payment (B1) measure. The TRG developed the policy parameters for the measure. The TRG met face-to-face five times and provided out-of-session advice on two occasions during 2009-10.The original patient eligibility criteria were linked to ‘chronic disease risk factors’ rather than ‘at risk of chronic disease’. Based on consultation with NACCHO, the eligibility criteria were expanded to patients with, or at risk of, chronic disease. Special arrangements were also developed based on consultation with NACCHO to allow for the participation of IHSs that cannot register for PIP Indigenous Health Incentive and where there is a large Aboriginal and Torres Strait Islander population. These organisations can apply directly to the department to participate in the PBS Co-payment (B1) measure. This accommodation allows for greater participation by the IHS sector. Mainstream general practices can also






apply for approval under special arrangements to ensure that Aboriginal and Torres Strait Islander people in areas with no access to PIP Indigenous Health Incentive can have access to the PBS Co-payment. Drafting of the Section 100 legislative instrument that enables the PBS Co-payment (B1) measure involved consultation with TRG members and DHS. The department engaged with the Medical Software Industry Association (MSIA) and DHS to develop the infrastructure to ensure processing of co-payments. Early in the 2009-10 financial year, the department worked with the MSIA to develop a resource document (PBS Co-payment measure Indigenous Health National Partnership – Vendor Resource Document for Health Industry Software Developers) to inform PBS prescribing and dispensing software vendors about the need to upgrade their software with CtG processing functionality. This document was finalised on 6 April 2010.The department executed funding agreements with PBS prescribing and dispensing software vendors to upgrade their software as specified in the resource document. With the exception of the Medical Director program, all PBS prescribing software was upgraded with CtG annotation functionality by 30 June 2010.The department worked with DHS to implement the system functionality to enable the capture of data relating to CtG prescriptions dispensed by approved suppliers, and also to enable the correct processing of co-payment reimbursement amounts to approved suppliers.In 2009-10, the PBS Co-payment (B1) measure was promoted through a number of channels. From December 2009, information about the PBS Co-payment (B1) measure was available for download from the department’s ICDP website, and the department issued regular advice about the measure through newsletters distributed by the Australian General Practice Network (AGPN), the Pharmacy Guild of Australia (the Guild), the Pharmaceutical Society of Australia (the PSA), Medicare e-Newsletter and other network opportunities.The PBS Co-payment (B1) measure group email and the PBS Co-payment Hotline were established to provide support to key stakeholders, including patients, from early January 2010. Staff from the department gave presentations about the PBS Co-payment measure to the AGPN (including State and Territory Affiliates), NACCHO (including State and Territory Affiliates), the Guild, the PSA, and DHS. Presentations were often provided more than twice.Towards the end of the 2009-10 financial year, the Pharmacy Staff Resource booklet was developed in consultation with the Guild and the PSA over a two and half month period, and published in June 2010. The Pharmacy Staff Resource booklet was distributed by mail to all registered community pharmacies. In 2009-10, the actual expenditure on the PBS Co-payment was $4.446 million.207

207 Based in information provided by the Department of Health and Ageing. 107





Three performance indicators for this measure are included in the Commonwealth Implementation Plan: number and locations of people accessing medicines through the program;

and number of practices, Indigenous Health Services and community pharmacies

participating in the program.Since the service delivery aspects of the PBS Co-payment (B1) measure were not scheduled to commence until 1 July 2010, there is no performance data to report against the Commonwealth Implementation Plan indicators for this time period.






9. Higher Utilisation Costs for MBS and PBS This measure provides increased funding to the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) to meet expected higher utilisation costs by Aboriginal and Torres Strait Islander people accessing programs under the ICDP. Unlike other ICDP measures, this measure is not a direct service strategy; rather it represents a budget provision in anticipation that other measures will increase Aboriginal and Torres Strait Islander access to and utilisation of the MBS and PBS. This chapter presents information about increased utilisation of MBS in the 2009-10 financial year and associated increases in expenditure. 9.1 Increased activityBetween the August quarter 2008 and the May quarter 2010 there was an increase in the number of services that are specifically provided to Aboriginal and Torres Strait Islander people by both medical practitioners and other workers. The number of health assessments and number of unique medical practitioners providing health assessments has increased over this period, as demonstrated in Figure 9 below.

Figure 9: Number of health assessments provided to Aboriginal and Torres Strait Islander people (MBS items 704, 706, 708, 710 and 715) and number of unique providers (i.e., medical practitioners) by Medicare quarter.208

There was variation at the jurisdiction level in the number of health assessments provided. Most jurisdictions showed growth in the number of health assessments provided over the period August 2008 to May 2010. As illustrated in Figure 10 below, almost all jurisdictions demonstrated a sharp increase in the number of

208 Based on MBS data supplied by Department of Health and Ageing109





services provided in May 2010. Seasonal variation (i.e., historically fewer services are provided in the February quarter) is a feature of the data.

Figure 10: Number of health assessments provided to Aboriginal and Torres Strait Islander people (MBS items 704, 706, 708, 710 and 715) by Medicare quarter and jurisdiction.209

Figure 11: Number of health assessments provided to Aboriginal and Torres Strait Islander people (MBS items 704, 706, 708, 710 and 715) by Medicare quarter and remoteness.210

209 Based on MBS data supplied by Department of Health and Ageing.210 Based on MBS data supplied by Department of Health and Ageing.






The ratio of health assessments to the number of providers increases with increasing remoteness. This is demonstrated in Table 9.Table 9: Average number of health assessments provided to Aboriginal and Torres Strait Islander people ((MBS items 704, 706, 708, 710 and 715) per unique provider by remoteness for May 2010 Medicare quarter, for selected jurisdictions.211

State/territory Major Cities

Inner Regional

Outer Regional

Remote Very Remote

New South Wales 3.6 8.0 10.0 18.8 N/AQueensland 6.2 5.8 9.4 12.7 22.0South Australia 3.0 3.9 3.5 4.0 13.0Western Australia 9.2 7.3 5.1 11.6 19.4Northern Territory N/A N/A 11.6 12.4 16.2In 2009-10 a change was made to the maximum number of follow up services Aboriginal and Torres Strait Islander people who receive a health assessment can access per year through MBS. Since this change, Aboriginal and Torres Strait Islander people are eligible for 10 follow up services per year from a practice nurse or registered Aboriginal Health Worker following a health assessment, rather than the previous five services per year.Most likely a result of this change, the number of follow up items provided by Aboriginal Health Workers or practice nurses (MBS item 10987) has increased over the period August 2008 to May 2010. This is also the case for the number of providers.

211 Based on MBS data supplied by Department of Health and Ageing.111





Figure 12: Number of follow up services (Item 10987) and unique providers by Medicare quarter.212

Figure 13 below presents statistics on the number of Aboriginal and Torres Strait Islander specific services provided by allied health workers under MBS arrangements. Across Australia there is growth in the number of these services being provided, however the overall number of services is quite low, compared to the number of health assessments or follow up services that are occurring.

212 Based on MBS data supplied by Department of Health and Ageing. 112





Figure 13: Number of services provided to Aboriginal and Torres Strait Islander people (MBS items 81300 to 81360) by Medicare quarter, for selected allied health workers.213

There has been mixed growth in the number of providers for allied health items 81300 to 81360. For many items, there were less than ten providers of the items in the May quarter of 2010. Of these allied health items only item 81335 (i.e., physiotherapists) had more than 100 providers in the May quarter of 2010.9.2 Increasing costs associated with activityTable 10 below provides information about MBS expenditure on Aboriginal and Torres Strait Islander specific MBS items in 2009-10. The data presented in Table10 below are national expenditure figures. Table 10: National MBS expenditure in 2009-10 on specific items.214

Item Number Item Description Expenditure715215 Aboriginal Health Assessment $9,192,199

10986Provision of a health assessment for a patient who is receiving or has received their four year old immunisation

$1,161,285

10987 Health assessment follow up from PN or AHW $71,577

213 Based on MBS data supplied by Department of Health and Ageing214 Medicare Australia 2011, Data online (website). 215 The item 715 refers to all Health Assessment items over the period (items replaced by item 715).




http://www.medicareaustralia.gov.au/provider/medicare/mbs.jsp#N1003F



Item Number Item Description Expenditure

10988 Immunisation provided to a person by an AHW $78,124

10989 Treatment of a person’s wound provided by an AHW $40,389

10997 Service provided to a person with a chronic disease by a PN or AHW $2,751,897

81300 Aboriginal and Torres Strait Islander Health Service $19,798

81305 Diabetes education health service $4,62981310 Audiology health service $54281315 Exercise physiology health service $6,06081320 Dietetics health service $8,14281325 Mental health service $44881330 Occupational therapy service $61181335 Physiotherapy health service $21,95781340 Podiatry health service $20,36281345 Chiropractic health service $92181355 Osteopathy health service $1,59681360 Psychology health service $5,615Total - $13,386,152

The subsequent monitoring reports will continue to track changes in Aboriginal and Torres Strait Islander MBS services, the number of providers supplying these services and the expenditure on these services.






10. Supporting Primary Care Providers to Coordinate Chronic Disease Management

Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a) measure at a glanceICDP priority area: Primary health care services that deliver.The issue being addressed: Aboriginal and Torres Strait Islander people experience a higher incidence of chronic disease than other Australians, and therefore have a higher need for better practice chronic disease management.The ICDP solution: The Practice Incentives Program (PIP) Indigenous Health Incentive provides tiered incentive payments for primary health care providers’ delivery of better practice chronic disease management. The measure also includes supports for implementation, including a cultural awareness training package, a program advisory body, and program guidelines. The supporting evidence: There is some evidence to suggest that practice-level incentives are effective in some settings to improve care. It is undetermined, however, whether these findings are supported in the context of provision of care to Aboriginal and Torres Strait Islander patients. The central causal pathway: The PIP Indigenous Health Incentive aims to create sustained improvements in relevant chronic disease clinical indicators. In order to achieve this outcome, the measure provides financial incentives to incite more primary health care providers to adopt better practice care in helping Aboriginal and Torres Strait Islander patients manage chronic disease. Reach: The reach of this measure is determined by the number and location of participating practices, and the number of registered Aboriginal and Torres Strait Islander patients who are receiving increased care. Timeframes: Within two to four years, primary health care practices are expected to provide better practice care in line with incentive requirements, and to possess enhanced awareness of Aboriginal and Torres Strait Islander culture. Within four years, participating patients should experience clinical improvements. These effects should be increased and sustained beyond this timeframe. Year one progress: In 2009-10 key activities that occurred within this measure included promotions to key stakeholders, registration of primary health care practices, and payments to practices according to the incentive scheme.






10.1 Design of the Supporting Primary Care Providers to Coordinate Chronic Disease Management (also referred to as PIP Indigenous Health Incentive measure)

The Practice Incentives Program (PIP) Indigenous Health Incentive is included in the pre-existing Practice Incentives Program administered by the Department of Human Services (Medicare Australia), which provides financial incentives to general practices and Indigenous health services (IHSs) (referred to as practices) to support delivery of care. The PIP Indigenous Health Incentive is composed of two core components: PIP Indigenous Health Incentive payments; and supports for implementation of the PIP Indigenous Health Incentive.The total budget for the measure for the first four years of the ICDP (from 2009-10 to 2012-13) is $27.879 million, including for PIP Indigenous Health Incentive payments and program supports. This represents an estimate of the likely cost of the measure; actual cost will depend on the uptake of payments (sign-on, patient registration and outcomes payments).

PIP Indigenous Health Incentive payments

There are four types of payments provided to participating practices within the PIP Indigenous Health Incentive216: sign-on payments; patient registration payments; Tier 1 outcomes payments; and Tier 2 outcomes payments. Sign-on payments are one time payments of $1000 for eligible practices which sign on to the incentive. Eligible practices are those that are accredited or registered for accreditation against the Royal Australian College of General Practitioners’ (RACGP) Standards for General Practices217 and which meet the sign-on requirements. Patient registration payments are annual payments of $250 to registered practices for each eligible patient that they register to receive chronic disease management. Patient re-registration is required on an annual basis and requires patient consent. Tier 1 outcomes payments are made to registered practices which provide specified chronic disease management services to registered patients. The payment is $100 per eligible patient per calendar year for each registered patient for whom a target level of care is provided by the practice. To receive this outcomes payment, the practice must provide the following services for the patient:

216 Department of Health and Ageing, Department of Human Services (Medicare Australia) 2010, Practice Incentives Program, Indigenous Health Incentive Guidelines – March 2010, viewed 23 August 2012.217 Royal Australian College of General Practitioners’ (RACGP) 2010, Standards for General Practices (4th edition), RACGP, South Melbourne, Australia.







prepare a GP Management Plan (GPMP) (MBS item 721) or coordinate the development of a Team Care Arrangement (TCA) (MBS item 723) for the patient in a calendar year, and undertake at least one review of the GPMP or the TCA (MBS item 732) during the calendar year; or

undertake two reviews of the patient’s GPMP or TCA during the calendar year (MBS item 732); or

contribute to a review of a multidisciplinary care plan for a patient in a Residential Aged Care Facility on two occasions during the calendar year (MBS item 731).

Tier 1 outcomes payments are paid in the quarter following the provision of services, based on claims against the MBS schedule.Tier 2 outcomes payments consist of $150 paid to practices for providing the majority of care for a registered patient in a calendar year. The majority of care “will be determined by the total number of eligible MBS services provided at the practice as a proportion of all eligible MBS services provided for the patient during the calendar year.”218 Practices are not obliged to conform to specified care expectations, such as those outlined for Tier 1, in order to receive a Tier 2 payment. Tier 2 outcomes payments are paid annually in February. Patients eligible for PIP Indigenous Health Incentive registration are Aboriginal and Torres Strait Islander people aged 15 years and older with a chronic disease. Patients must self-identify as Aboriginal and Torres Strait Islander and provide consent for registration under the PIP Indigenous Health Incentive. Consent is granted through a patient consent form, which is signed and returned to DHS. The PIP Indigenous Health Incentive uses the MBS definition of a chronic disease, which is a disease that has been, or is likely to be, present for at least six months, including but not limited to asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions and stroke.219 More than one general practice may register a client and receive outcomes payments (Tier 1 or Tier 2), but the patient registration payment is provided to the first registering practice. This is intended to be the patient’s ‘usual care provider’, who has provided or will provide the majority of care to the patient. As part of the registration agreement, the practice agrees that health care providers will undertake cultural awareness training, and that they will offer the patient a health check.

Program supports

In addition to the PIP Indigenous Health Incentive payments, this measure includes a number of program supports. These include requirements and support for cultural awareness training, a program advisory body, and program guidelines.

218 Royal Australian College of General Practitioners’ (RACGP) 2010, Standards for General Practices (4th edition), RACGP, South Melbourne, Australia.219 Department of Health and Ageing, Department of Human Services, n.d., Practice Incentives Program Indigenous Health Incentive, Frequently Asked Questions, viewed September 2012.




http://www.health.gov.au/internet/ctg/publishing.nsf/Content/practice-incentives-program/$file/PIP-FAQ.pdf




As a pre-requisite to participating in the program, practices are required to ensure their registered health professionals receive cultural awareness training. To meet the minimal requirements, at least two staff members from the practice (one of whom must be a GP) must complete appropriate cultural awareness training within 12 months of the practice signing on to the incentive.220 In support of this, the department has provided funding to the RACGP to develop an online cultural awareness training module. The six-hour online module is available free of charge to practices participating in the PIP Indigenous Health Incentive.221 Other training programs that meet the requirements for cultural awareness training are those that are endorsed by a professional medical college or by the National Aboriginal Community Controlled Health Organisation (NACCHO) or one of its state or territory affiliates. The department has developed program guidelines that define the expectations of the measure to eligible practices.222 DHS promotes the PIP Indigenous Health Incentive through its website, via quarterly newsletters to healthcare professionals (Forum) and through quarterly news updates to PIP registered practices.

Stakeholders

below provides an overview of the key stakeholder groups and their roles in relation to the PIP Indigenous Health Incentive measure.

220Department of Health and Ageing, Department of Human Services, n.d., Practice Incentives Program Indigenous Health Incentive, Frequently Asked Questions, viewed September 2012.221 Royal Australian College of General Practitioners 2011, Cultural awareness education and cultural safety training. 222 Department of Health and Ageing, Department of Human Services (Medicare Australia) 2010, Practice Incentives Program, Indigenous Health Incentive Guidelines – March 2010, viewed 23 August 2012.





http://www.racgp.org.au/download/Documents/AHU/2011culturalawareness.pdf

http://www.racgp.org.au/download/Documents/AHU/2011culturalawareness.pdf





Table 11: Key stakeholders and roles in relation to the PIP Indigenous Health Incentive measure.223

Stakeholder Role in PIP Indigenous Health Incentive measure


Manage PIP Indigenous Health Incentive measureDevelop program guidelinesReport on progress towards targets in Commonwealth Implementation Plan

Department of Human Services (Medicare Australia)

Administer PIP Indigenous Health Incentive measure payments

Indigenous health services / providers

Register for the PIP Indigenous Health IncentiveRegister consenting patientsProvide care for registered patientsUndertake cultural awareness trainingBill for services and receive incentive payments

Mainstream primary health care practices / health care providers

Register for the PIP Indigenous Health IncentiveRegister consenting patientsProvide care for registered patientsUndertake cultural awareness trainingBill for services and receive incentive payments

Aboriginal and Torres Strait Islander patients

Provide consent for registrationReceive care from PIP Indigenous Health Incentive-registered providers

Royal Australian College of General Practitioners

Develop and provide access to online cultural awareness training

PIP Advisory group

Provide advice on the design and implementation of the PIP Indigenous Health Incentive (see below)

The PIP Advisory Group is a pre-existing advisory group which provides advice on the PIP overall, and was being used to advise more specifically on the design and implementation of the PIP Indigenous Health Incentive as well as the ICDP Care Coordination and Supplementary Services (CCSS) measure (see chapter 11). The PIP Advisory Group meets two to three times a year. For the purpose of the PIP Indigenous Health Incentive measure, the membership of the PIP Advisory Group was expanded to ensure appropriate consultation. Usual members of the Advisory include representatives from the following organisations: Australian College of Rural and Remote Medicine;

223 Based on information provided by the Department of Health and Ageing. 119





Australian General Practice Network; Australian Medical Association; Royal Australian College of General Practitioners; and Rural Doctors Association of Australia. For the purpose of PIP Indigenous Health Incentive, membership was extended to the: National Aboriginal Community Controlled Health Organisation; and Australian Indigenous Doctors’ Association.


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).224 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the PIP Indigenous Health Incentive.Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The PIP Indigenous Health Incentive supports the core aims and targets of

Closing the Gap by providing incentives for chronic disease management care planning and other health services by primary health care practices. As a result, Aboriginal and Torres Strait Islander people are expected to achieve improved health outcomes.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. The expanded PIP Advisory Group has been engaged in consultation on the

design and delivery of the PIP Indigenous Health Incentive, including representatives from two Aboriginal and Torres Strait Islander organisations.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The measure is funded over the first four years from 2009-10 to 2012-13. The

PIP Indigenous Health Incentive is expected to result in improved cultural awareness of and better practice care for Aboriginal and Torres Strait Islander people, which could be sustained beyond the initial funding timeframe.


Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs.









The PIP Indigenous Health Incentive includes the requirement for GP private practices to participate in cultural awareness training in order to enhance the cultural accessibility of the practice and care delivery for Aboriginal and Torres Strait Islander people.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. There is ongoing collaboration between the department and DHS to ensure

administration and coordination. Collaboration has included development of a memorandum of understanding and business practice agreement, and regular meetings and correspondence between the organisations.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. The PIP Indigenous Health Incentive is included in two ICDP evaluation

projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

DHS provides the department with quarterly reports on progress towards targets.

10.2 Rationale and supporting evidenceThis section outlines the rationale for the measure and the evidence that supports its design. The PIP Indigenous Health Incentive aims to support general practices and Indigenous health services (IHSs) to provide better health care for Aboriginal and Torres Strait Islander patients, including better practice management of chronic disease through the provision of incentive payments and cultural awareness training. Aboriginal and Torres Strait Islander people experience a higher incidence of chronic disease than other Australians, yet have lower rates of access to primary health care services.225 In particular, this population’s access to general practice is considerably lower than that of other Australians.

Evidence related to incentive payments

Australian research has shown that incentive reform can have a positive effect on quality of care in diabetes management.226 There is also evidence linking the use of incentive payments to improved care coordination.227

225 Deeble J, Shelton Agar J & Goss J 2008, ‘Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004–2005’, Health and welfare expenditure series, no. 33, AIHW, Canberra. 226 Scott A, Schurer S, Jensen PH & Sivey P 2008, ‘The effect of financial incentives on quality of care: The case of diabetes’, Working Paper 12/08, Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Victoria. 227 OECD 2007, ‘Improved health system performance through better care coordination’, Working Paper No. 30 cited in Department of Health and Ageing 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed August 2011.








A review by Couzos et al. in 2010 found limited evidence linking use of incentive payments to impacts on Aboriginal and Torres Strait Islander patients. This review noted “certain assumptions underpin the rationale for this [Indigenous] health incentive”228 including: that incentive payments increase this population’s access to mainstream general practice; that increases in service delivery will be geared to those with chronic and complex diseases; and that consultations resulting from such incentives will result in improved care. However, support for these assumptions is unclear. Other studies have corroborated this view; a report by the Australian National University calling for further research into the impact of incentive payments within primary health care also notes that little is known about the impact of such payments.229

Some investigators have identified a number of potential negative barriers to the uptake of incentive programs (such as the PIP) among Indigenous health services including: not meeting eligibility criteria to receive payments; issues with identification of Aboriginal and Torres Strait Islander patients; and the high mobility of this population.230,231 It has been found that Indigenous health services which are registered in other PIP programs may have difficulties in meeting requirements for ongoing and structured contact with patients, potentially impacting on the uptake of the PIP. This may in turn limit Aboriginal and Torres Strait Islander access to PIP. It is suggested that, broadly, the impact of the PIP on Indigenous Health Services has been limited. Analysis has suggested that strategies to increase the use of PIP incentive payments by Indigenous Health Services include the incorporation of culturally accessible information into the PIP.232 Despite some concerns, researchers note that the PIP Indigenous Health Incentive provides an opportunity to test some of the assumptions and provide evidence for the impact of incentive payments in Aboriginal and Torres Strait Islander health.233

Evidence related to PIP Indigenous Health Incentive program supports: cultural awareness training

Research suggests that provision of culturally appropriate care and improved cultural competency of mainstream health services can improve patient

228 Couzos S & Thiele DD 2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, p. 156.229 Australian National University 2008, Media Release: Incentive pay for GPs to be explored by researchers.230 Couzos S & Thiele DD 2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, p. 156.231 Urbis Keys Young 2006, Aboriginal and Torres Strait Islander Access to Major Health Programs, Urbis JHD Group, Sydney.232 Urbis Keys Young 2006, Aboriginal and Torres Strait Islander Access to Major Health Programs, Urbis JHD Group, Sydney.233 Couzos S & Thiele DD 2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, p. 156.






access234, and lead to improvements in patient care.235 A report on a New South Wales mainstream primary health care service notes that cultural awareness training was identified by health professionals and Aboriginal and Torres Strait Islander patients as a potential way to improve the latter’s access to mainstream GP services.236

Research suggests that there are a number of critical determinants in effective delivery of cultural awareness or competency training to GPs, including partnerships with local IHSs and peak bodies237 to support development, implementation and evaluation of training, organisational commitment to training, clarity around the purpose, role and learning objectives of training, and the development and use of self-directed learning resources for GPs.238

10.3 Central causal pathwayThe intended outcomes of the PIP Indigenous Health Incentive should occur over the short, medium and long term. These intended outcomes are influenced by factors within and outside of the measure. The expected results that should occur in encouraging primary health practices to deliver better chronic condition care to Aboriginal and Torres Strait Islander patients as a result of the activities of this measure represent a ‘causal pathway’.The diagram below reflects KPMG’s interpretation of the central causal pathway that is inferred from the measure’s design. It illustrates the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (represented by dark text bubbles linked by arrows) and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other over time (represented by light text boxes).

234 Aboriginal Health and Medical Research Council Consulting Service & Mandala Consulting 2004, Increasing access to Services in NSW for Aboriginal People at Risk of Contracting of Who Have Blood Borne Infections, NSP Annual Report, NSW.235 Lawrence M 2009, Improving the Patient Journey: Achieving Positive Outcomes for Remote Aboriginal Cardiac Patients, Cooperative Research Centre for Aboriginal Health, Darwin.236 Andrews B, Simmons P, Long I & Wilson R 2002, Identifying and Overcoming the Barriers to Aboriginal Access to General Practitioner Services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, pp. 196-201. 237 Urbis Keys Young 2006, Aboriginal and Torres Strait Islander Access to Major Health Programs, Urbis JHD Group, Sydney.238 Martin ME & Reath JS 2011, ‘General practice training in Aboriginal and Torres Strait Islander Health’, Medical Journal of Australia, vol. 194, no. 1, pp S67-S70.






PIP Indigenous Health Incentive

Increase in care providers’ cultural awareness

Increase in better practice care for chronic disease

management

Provider motivation to

change

Increase in care providers’ willingness to provide better practice care to


Improved identification of Aboriginal and Torres Strait

Islander patients who require enhanced chronic

disease care and management



Increase in care providers' knowledge, understanding

and skills



Incentive

Incentive payments and other benefits outweigh administrative cost to primary health care

practices

Cultural awareness training is

appropriate and effective


Islander patients participate

Figure 14: PIP Indigenous Health Incentive causal model. Source: KPMG. 10.4 Reach and timeframesThe potential reach239 of the measure will be determined by factors including the number and location of participating practices (e.g., 70 of the 225 Indigenous health services240 had registered for the PIP Indigenous Health Incentive in May 2010), and the number of registered Aboriginal and Torres Strait Islander patients who are receiving increased care. The anticipated early results of the PIP Indigenous Health Incentive measure (years two to four) include implementation according to program guidelines, and delivery of Tier 1 and Tier 2 care by registered practices to registered Aboriginal and Torres Strait Islander patients.241 Within this timeframe, it is expected that health care professionals in registered practices will have an increased understanding of Aboriginal and Torres Strait Islander cultures and better practice care appropriate for this population. Given this increased exposure and capability, it is expected that the PIP Indigenous Health Incentive will result in a greater volume of service delivery for Aboriginal and Torres Strait Islander patients with chronic disease.In the medium to longer term (four years or more), participating practices are expected to build and sustain their capacity to deliver Tier 1 and Tier 2 standards of care to patients. At a system level, general practices and IHSs will have increased and sustainable capacity to deliver better practice care to Aboriginal and Torres Strait Islander patients with chronic disease. At an individual level, participating patients are expected to achieve sustained reductions in clinical risk factors associated with chronic disease. 10.5 Complementary activityStates and territories are providing initiatives to promote better practice chronic disease care to Aboriginal and Torres Strait Islander patients. Refer to Appendix B for further information on stakeholders consulted. 239 The term ‘reach’ in this Report refers to the potential and actual penetration of the measure’s impact on the intended target group.240 Australian Institute of Health and Welfare 2011, Aboriginal and Torres Strait Islander health services report 2009–10: OATSIH Services Reporting—key results, cat. no. IHW 56, AIHW, Canberra.241 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume s1,2 &3, Department of Health and Ageing, Canberra.








Within ICDP, synergies exist with other measures to support the desired outcomes. The PBS Co-payment (B1) measure promotes patient involvement in the PIP Indigenous Health Incentive in providing a further benefit for participation: the potential to receive free or lower cost medications from a PIP Indigenous Health Incentive-registered practice. ICDP workers provide additional supports to the PIP Indigenous Health Incentive measure by promoting utilisation of primary health care services and directly supporting better practice care delivery. Examples include Healthy Lifestyle Workers (Helping Indigenous Australians Reduce Their Risk of Chronic Disease measure) who actively promote health checks and Care Coordinators (Care Coordination and Supplementary Services Program measure) who coordinate care for patients referred by participating practices. The PIP Indigenous Health Incentive measure provides a gateway to participation in two other ICDP measures: the PBS Co-payment (B1) measure; and the Care Coordination and Supplementary Services (CCSS) Program (B3b) measure. Only practices that are registered for the PIP Indigenous Health Incentive may participate in the PBS Co-payment and CCSS measures. Furthermore, referrals to specialists and allied health may occur as a result of this measure, creating a potential link to the Increasing Access to Specialist Care, and Specialists and Multidisciplinary Team Care (B5a and b) measures.Many of the other ICDP measures may have specific activities that increase the use of primary health care services by Aboriginal and Torres Strait Islander people. Increased awareness and utilisation of services could increase the likelihood of practice participation, patient registration, and subsequently of Tier 1 and Tier 2 payments. These initiatives include the activities undertaken by Healthy Lifestyle Workers (A2) measure, Local Community Campaigns (A3) measure and Care Coordinators (B3b) measure. Furthermore, other elements of ICDP that seek to enhance the practice capacity could support primary health care services to take up PIP Indigenous Health Incentive. This may occur through Practice Managers funded in IHSs (Expanding the Outreach and Service Capacity of Indigenous Health Organisations) and Indigenous Health Project Officers (IHPOs) funded in mainstream primary health care practices (Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care).The PIP Indigenous Health Incentive is also related to the Clinical Practice and Decision Support Guidelines (C5) measure, in that PIP Indigenous Health Incentive practices may benefit from utilising the available resources in providing better practice care to Aboriginal and Torres Strait Islander patients. Finally, the Higher Utilisation Costs for MBS and PBS (B2) measure is directly linked to measures which directly or indirectly increase access to MBS such as this PIP Indigenous Health Incentive measure.Refer to Appendix C for more information on the key synergies between the different measures of the ICDP.






10.6 PIP Indigenous Health Incentive data sources This measure will be informed by a number of primary and secondary data sources. Primary data sources will include consultations with mainstream and IHS providers, community members and other stakeholders, review of program documentation, organisational and workforce surveys and the PIP Advisory Group. Secondary sources include the MBS data and PIP Indigenous Health Incentive registration and payment data. Clinical data from participating health services may also be used pending negotiation of access with individual organisations and communities. Secondary data sources are discussed in more detail in Appendix E. The Evaluation Framework242 identifies two indicators to measure the whole of Package which are directly relevant to this measure. These are: Self-reported access to health services, as reported in section 3.12 of the HPF.

In 2008, 30 per cent of Aboriginal and Torres Strait Islander people over age 15 reported problems accessing health services.

Proportion of Aboriginal and Torres Strait Islander people with Type II diabetes to receive recommended care, as reported in section 3.04 of the HPF. In the first half of 2009, 50 per cent of regular clients with Type II diabetes had an HbA1c test in the last six months.

Refer to Appendix F for further information about these indicators, including original sources. The evaluation will monitor and provide updates on these indicators as they become available.10.7 Year one progressIn 2009-10, the Minister for Indigenous Health approved the requirements for the PIP Indigenous Health Incentive and the implementation arrangements. This followed extensive consultation with the Department of Human Services (Medicare Australia) to develop business rules for administration of the measure, including identification of required systems and related costs. A number of promotional channels were utilised in 2009-10 to promote the PIP Indigenous Health Incentive to practices. DHS sent two letters of invitation to PIP-registered practices informing them of the opportunity to participate in the PIP Indigenous Health Incentive (December 2009 and March 2010). DHS sent similar promotional letters to non-PIP registered IHSs in January 2010. The PIP Indigenous Health Incentive was featured in newsletter articles in the PIP News Update, a quarterly publication sent through DHS (November 2009, February 2010 and May 2010). The DHS Forum, published quarterly, also features information on the PIP Indigenous Health Incentive in Autumn 2010. The DHS website has included information on the PIP Indigenous Health Incentive throughout 2009-10. IHPOs employed under the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure commenced employment from October 2009. IHPOs work closely with

242 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.








mainstream primary care providers to raise awareness of the PIP Indigenous Health Incentive.The Department of Health and Ageing funded RACGP in June 2010 to develop an online cultural awareness training module.Two performance indicators for this measure are included in the Commonwealth Implementation Plan: Number of PIP practices signed on to the incentive. Number of practices receiving payments for registering patients.243

MBS data for the May quarter 2010 provides an indication as to the initial uptake of PIP Indigenous Health Incentive. There were 853 practices that had received payments for signing up in the May 2010 quarter. shows that more mainstream general practices than IHSs have signed up for PIP Indigenous Health Incentive; however, there is a much larger pool of mainstream practices which are eligible to sign-up. Table 12: Number of practices registered, patients registered for the PIP Indigenous Health Incentive payments as at May quarter 2010 by practice type.244

Practices or patients

Indigenous health service

General practice Total

Practices 70 783 853Patients 1,857 1,070 2,927

IHSs have generally registered more patients than mainstream practices, as demonstrated in Table 13 below. Outer regional Australia had the highest average number of patients registered per practice (compared to other regions defined by remoteness).

243 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra. 244 Based on MBS data supplied by the Department of Health and Ageing.






Table 13: Number of practices registered, and patients registered for the PIP Indigenous Health Incentive payments as at May quarter 2010 by remoteness and service type.245

Remoteness classification

Indigenous health service – practice registrations

General practice – practice registrations

Average Indigenous health service – patient registration

Average General practice – patient registration

Major Cities of Australia

11 444 23.2 0.3

Inner Regional Australia

24 172 28.2 0.7

Outer Regional Australia

22 113 38.0 3.6

Remote Australia 8 41 9.8 5.4Very Remote Australia

5 13 2.0 13.6

Total 70 783 26.5 1.4

Practice registration for the PIP Indigenous Health Incentive has been much lower than initially estimated, while patient registration has been much higher. below presents the anticipated and actual registrations in 2009-10.

245 Based on MBS data supplied by the Department of Health and Ageing.128





Table 14: Number of anticipated and actual practices registered for the Indigenous Health Incentive, 2009-10.246

Registered practices and patients

Anticipated Actual

Number of registered practices

4,298 853

Number of registered patients* (as of May 2010)

1,505 2,927

*Note: patient registration and re-registration is made on the basis of calendar yearThis is despite the fact that the promotional channels to advertise the PIP Indigenous Health Incentive are focused on primary health care practices and have precluded promotions to the public. Due to privacy considerations that limit the publication of details on private GP practices, DHS cannot provide Aboriginal and Torres Strait Islander patients with a listing of practices that are participating in the PIP Indigenous Health Incentive. This was identified as a potential barrier to access during consultations undertaken for the Baseline Report.






11. Supporting Primary Care Providers to Coordinate Chronic Disease Management

Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3b) at a glanceICDP priority area: Primary health care services that deliver.The issue being addressed: Patients with multiple, complex chronic diseases, limited capacity to effectively navigate the health care system and experiencing financial disadvantage are more likely to experience negative health outcomes. Many Aboriginal and Torres Strait Islander people fall into these categories, so provision of care coordination and of funding to support access to health care has the potential to address these inequities and improve health outcomes for Aboriginal and Torres Strait Islander patients. The ICDP solution: This measure establishes a Care Coordinator workforce, and provides a pool of funds to support access to necessary services. The supporting evidence: Evidence suggests that care coordination can lead to improved access to services and greater adherence to care plans. Care coordination has been shown to improve outcomes for Aboriginal and Torres Strait Islander patients when appropriate referrals are made and patients are assisted to navigate the health service system. The central causal pathway: The measure aims to achieve sustained improvements in relevant chronic disease clinical indicators. In order to achieve this outcome, the measure enhances the capacity of the primary health care system to provide coordinated, collaborative care and support for patients with multiple and complex needs, and addresses barriers such as service fees and transport to improve access to necessary care. Reach: The potential reach of the measure is primarily determined by the number of patients registered for PIP Indigenous Health Incentive, the number of Care Coordinators and their proximity and connection to referring practices and the number of eligible Aboriginal and Torres Strait Islander patients accessing eligible primary health care practices.Timeframes: It is envisaged that within two to four years, the service system will have increased capacity to improve coordination of care through referral of patients to Care Coordinators; as a result, patients are anticipated to have increased adherence to their care plans. These impacts will be sustained and enhanced over the life of the measure, resulting in greater participation and clinical improvements for participating patients within four years. Year one progress: In the first year of implementation (2009-10), key activities undertaken within this measure included departmental consultations with key stakeholders, and the execution of funding agreements to manage funds in each state and territory.






11.1 Design of the Supporting Primary Care Providers to Coordinate Chronic Disease Management measure (also referred to as the CCSS measure)

The CCSS measure is provided through three core components: Care Coordinator workforce; Supplementary Services funding pool; and program supports.The total budget for the CCSS measure for the duration of the ICDP (from 2009-10 to 2012-13) was $83.94 million.

Care Coordinator workforce

Within the context of the CCSS measure, care coordination is defined as “working collaboratively with patients, and general practices and Indigenous health services to assist in the provision of care and services that facilitate a person with a chronic condition to manage their health in a way that will result in the optimal health outcome for them.”247 These activities can include: explaining medical concepts to a patient in a way that ensures they

comprehend; making health care appointments for a patient, including for specialists,

primary and allied health services; supporting a patient to attend health care appointments (such as by

reminding the patient of the appointment, organising transport to and from the appointment, and/or sitting in on the appointment with the patient);

following up with the patient on progress against their care plan248 developed by their GP, including supporting the patient to: - better self manage their condition; - adhere to their treatments regimen (such as medications); and- connect with community based services, as relevant.

liaising with the patient’s referring GP on the progress and needs of the patient; and

transferring and updating a patient’s medical records. 249

It is expected that Care Coordinators work collaboratively with other services in their local area, both mainstream and Aboriginal and Torres Strait Islander-247 Australian Government Department of Health and Ageing 2010, Indigenous Chronic Disease Package Care Coordination and Supplementary Services, Program Guidelines, viewed September 2012.248 Care plan refers to a plan developed by a GP to manage a patient’s chronic disease, usually a GP Management Plan (GPMP) and/or Team Care Arrangement (TCA).249 Australian Government Department of Health and Ageing 2010, Indigenous Chronic Disease Package Care Coordination and Supplementary Services, Program Guidelines, viewed September 2012.




http://www.health.gov.au/internet/ctg/publishing.nsf/Content/CA2578620005D837CA257AC3000DEA58/$File/Care%20coordination%20guidelines%20REVISED%20Nov%202012.pdf






specific, to link patients with the range of services they need but might not be aware of or utilise. The Care Coordinator’s role includes elements of both ‘care coordination’ focused on aspects of clinical care, and ‘service coordination’ focused on navigating the health service system.250 Care Coordinators are qualified health workers who have clinical knowledge of chronic disease and who are focused on health care for Aboriginal and Torres Strait Islander people. Examples of professional background of Care Coordinators include Aboriginal Health Workers (AHWs) and nurses. Beyond the need for Care Coordinators to have clinical skills and cultural sensitivity, the CCSS measure guidelines state: “Consideration could be given to other appropriate qualifications and training, other skill requirements and personal attributes in specific circumstances and in consultation with the Department of Health and Ageing.”251 While the main duty of Care Coordinators is to provide coordination services (i.e., non-clinical), Care Coordinators may provide some clinical services depending on their background and qualifications. Care Coordinators accept referrals from participating health care providers for patients requiring complex care. In order to receive Care Coordinator services, patients must be registered with a GP within a primary health care practice participating in the PIP Indigenous Health Incentive (B3a measure). The referring GP must determine that the patient has one of the five chronic diseases targeted by the ICDP (diabetes, cardiovascular disease, chronic respiratory disease, chronic renal disease and cancer); and that they would achieve improved health outcomes as a result of receiving care coordination services. The referring GP must prepare a care plan for the patient. The program guidelines suggest that patients be referred to a Care Coordinator on a priority basis, including patients who: are at greatest risk of experiencing avoidable hospital admissions or other inappropriate use of services; need help to overcome barriers to service access; have low health literacy; and/or who require more intensive care coordination than is otherwise available through providers.252 It is the role of the Care Coordinator to coordinate the implementation of the patient’s care plan in liaison with the patient and relevant health care providers. As part of this process, Care Coordinators may make appointments for specialist or allied health services (including USOAP and MSOAP-ICD outreach services), connect the patient to Aboriginal and Torres Strait Islander Outreach Workers (under the ICDP Expanding the Outreach and Service Capacity of Indigenous Health Organisations Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care measures), and may provide patient education (e.g., assistance with self management) as their skills permit. 250 Australian Government Department of Health and Ageing 2010, Indigenous Chronic Disease Package Care Coordination and Supplementary Services, Program Guidelines, viewed September 2012.251 Australian Government Department of Health and Ageing 2010, Indigenous Chronic Disease Package Care Coordination and Supplementary Services, Program Guidelines, viewed September 2012, p.9252 Australian Government Department of Health and Ageing 2010, Indigenous Chronic Disease Package Care Coordination and Supplementary Services, Program Guidelines, viewed September 2012.












The Care Coordinator must provide feedback to the GP about follow up services accessed, the patient’s self management skills and behaviour, and the patient’s local/home environment. Other issues that may impact the patient’s health can also be included in feedback. Care Coordinators are expected to work in collaboration with other local services for Aboriginal and Torres Strait Islander people with a chronic disease. A patient’s access to the Care Coordinator will be ongoing while the need for assistance remains.Care Coordinator funding has been provided to the eight State Based Organisations (SBOs) of the Divisions of General Practice across Australia, to act as fund holders. Funding for Care Coordinator positions is in turn subcontracted by the SBOs to Divisions of General Practice, IHSs and other organisations.253 The location of Care Coordinator positions has been selected on a priority basis with advice from Indigenous Health Partnership Forums in each state or territory. Funding provided for the Care Coordinator workforce may be applied to salary, service support costs such as travel and office space, recruitment costs, and program administration.254 Care Coordinator service delivery may be provided through various arrangements, such as full or part time employment of an additionally created position, or expanding the role of a current position.

Supplementary Services Funding Pool

The Supplementary Services Funding Pool is composed of funds to be utilised at the discretion of the Care Coordinator to expedite patient access to urgently required services by allowing for the purchase of services from the private health care system. Care Coordinators are to allocate funds to a patient on a priority basis, as it is not expected that the fund will cover all follow up care for patients within the CCSS measure. Access to the private health care system is expected to reduce the wait time for service. The Supplementary Services Funding Pool may also be used towards the cost of local transportation of patients to health care appointments where this is necessary to access the required health care in a clinically appropriate timeframe. Local transport refers to assistance to attend the patient’s closest regionally available specialist.

Program supports

There are a number of program supports for the CCSS (B3b) measure, including a National Coordinator and program guidelines. The role of the National Coordinator, appointed in the Australian General Practice Network, is to provide leadership and support to Care Coordinators for the delivery of the measure.

253 Organisational arrangements have since changed with the advent of Medicare Locals. This has occurred subsequent to the reporting timeframe for this report and will be discussed in later evaluation reports.254






Program guidelines have been developed in consultation with the expanded Practice Incentives Program (PIP) Advisory Group (see section ) and provided to fund holders. Program supports also include promotional channels to promote the CCSS with health care providers, such as through Indigenous Health Project Officers (under the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure) and newsletters to PIP-registered practices.

Stakeholders

The stakeholders of this measure include internal and external parties at local/community, regional, jurisdictional and national levels. Table 15 below provides an overview of the key stakeholder groups and their roles in relation to the CCSS (B3b) measure.






Table 15: Key stakeholders and roles in relation to the CCSS measure.255

Stakeholder Role in CCSS (B3b) measureDepartment Central Office

Develop program designProvide oversight to Department State and Territory OfficesCoordinate national-level monitoring and reporting

Department state / territory offices

Manage funding agreements in the jurisdictions

Indigenous Health Partnership Forum

Provide SBOs with advice on priority locations for Care Coordinator workforce

PIP Advisory Group

Provide advice on CCSS program guidelines and implementationThe PIP Advisory Group was utilised to provide advice on the implementation of the CCSS measure. For the purposes of advising on the CCSS measure, membership has been extended to the National Aboriginal Community Controlled Health Organisation (NACCHO) and Australian Indigenous Doctors Association (AIDA).

Australian General Practice Network Host National Coordinator position

National Coordinator

Provide leadership to Care Coordinators located in Divisions of General Practice Network

State Based Organisations

Fund holders; administer program funding and manage program deliverySubmit a completed performance indicators reporting template, along with six-monthly and annual Progress Reports


Sub-contracted to SBOsHost Care Coordinator positions

Primary health care providers registered with PIP Indigenous Health Incentive

Refer patients to Care CoordinatorDiscuss patient care with Care Coordinator

Health care providers involved in implementation of care plan

Provide care as per the care plan and discuss patient care with Care Coordinator






Stakeholder Role in CCSS (B3b) measureCare providers not involved in the care plan

Provide services which are identified as necessary to support effective chronic disease management as the care plan is progressively implemented, such as social services.

Care Coordinators Provide care coordination services to patientsLiaise with referring practice and other health care providers involved in care planAccess and allocate Supplementary Services Fund

Aboriginal and Torres Strait Islander patients registered with PIP Indigenous Health Incentive

Receive care coordination servicesReceive services funded through Supplementary Services Fund


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).256 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the CCSS (B3b) measure.Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The measure supports the core aims and targets of Closing the Gap by

enhancing care coordination for Aboriginal and Torres Strait Islander people with chronic disease. Improved coordination of chronic disease management is expected to result in improved health outcomes.

Fund holders (SBOs) are required to consult with the Indigenous Health Partnership Forums (IHPFs) to assist with identification of priority locations for delivery of the CCSS (B3b) measure.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. The expanded PIP Advisory Group has been consulted for the implementation

arrangements for the CCSS (B3b) measure; this group includes representation from NACCHO and AIDA.

In addition, SBO fund holders are required to consult with IHPFs regarding identification of priority areas for service delivery and appropriate service delivery models.









Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The CCSS measure is funded over the first four years – 2009-10 to 2012-13,

with additional investment enhancing the reach of the program each year. The sustainability of the measure will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. CCSS program guidelines indicate that programs and services must be

physically and culturally accessible to Aboriginal and Torres Strait Islander people.

Care Coordinators are required to have the ability to provide services in a culturally sensitive way.

Participating general practices must be PIP Indigenous Health Incentive registered, a condition of which is that staff have had cultural awareness training.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. OATSIH and the department’s state and territory offices were consulted

during the development of the CCSS (B3b) measure. Communication with these stakeholders is ongoing to ensure coordination with other ICDP measures.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. Fund holders for this measure provide regular formal reporting as required in

the funding agreement with the department. The CCSS (B3b) measure is included in two ICDP evaluation projects – the

Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

11.2 Rationale and supporting evidenceThe CCSS (B3b) measure is premised on the rationale that Aboriginal and Torres Strait Islander patients with chronic disease can benefit from care coordination services. It is widely acknowledged that patients with one or more chronic diseases have highly complex care needs that can be difficult to manage.Despite the fact that they experience high levels of chronic disease, Aboriginal and Torres Strait Islander people often have limited access to health providers who are essential in the management of chronic conditions, such as general practitioners.257

257 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, no. 4, pp. 196-201.






The evidence also suggests that lack of collaboration and linkages between services, in particular between mainstream and IHS providers has a negative impact on provision of effectively coordinated care.258 For instance, many GPs are not aware of AHWs in their local region259, thus impacting on their ability to make referrals to an AHW to provide culturally appropriate support. Disconnects between primary health care providers and specialist medical practitioners are also confusing for patients260 and this may result in people disengaging with the health care system.Research evidence shows that formal care coordination mechanisms can be beneficial for Aboriginal and Torres Strait Islander patients, particularly when a key worker or case manager is engaged to actively coordinate care for patients.261

Evidence related to Care Coordinator workforce

Research shows that collaboration between service providers involved in the delivery of an individual’s care can lead to the individual’s increased engagement with services and improved clinical outcomes.262 This is particularly apparent when collaboration is supported by community involvement (i.e., AHW involvement, engagement of the individual) in the planning and delivery of services.263

Care coordination, where collaboration between multiple service providers is planned and/or coordinated by a person dedicated to this function (such as a care coordinator or case manager), has been shown to lead to adherence to care plans264, more systematic and timely delivery of services, enhanced participation by consumers in decisions related to their own health care, more effective clinical prevention and management of existing conditions265 and more effective chronic disease prevention and management programs.266

258 Hayman NE, Wenitong M, Zangger JA & Hall EM 2006, ‘Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples’, Medical Journal of Australia, vol. 184, no. 10, pp. 485-486.259 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, no. 4, pp. 196-201.260 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.261 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.262 Reath J & Carey M 2008, ‘Breast and cervical cancer in indigenous women – overcoming barriers to early detection’, Australian Family Physician, vol. 37, no. 3, pp. 178-182.263 New South Wales Health2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health,Sydney.264 Robinson G, d’Abbs P, Bailie R & Togni S 2003, ‘Aboriginal Participation in Health Service Delivery: Coordinated Care Trials in the Northern Territory of Australia’, International Journal of Services Technology and Management, vol. 5, pp. 45-62.












Elements of effective care coordination programs are: clearly defined roles and responsibilities of involved parties, linking of care protocols to existing practice and the articulation of appropriate responses in a variety of circumstances.267

More specifically, for Aboriginal and Torres Strait Islander people, effective care coordination includes making referrals to appropriate services, assisting patients to navigate the service system, and providing follow up support – both formal and informal – regarding client needs.268 Goal setting and monitoring processes (such as those implemented as part of a patient care plan) – when modified to be culturally inclusive of Aboriginal people – have been shown to be effective in improving the health-related behaviours of Aboriginal and Torres Strait Islander patients with chronic disease.269

Evidence related to Supplementary Services funding pool

The supplementary services funds are primarily provided to help purchase services from the private health care sector (either by covering the full or gap amount) with an aim to increase access to allied and specialist services and to reduce the waiting time experienced by Aboriginal and Torres Strait Islander patients who may otherwise be subject to detrimental wait times in the public system. The funds can also be used to support transport to appointments and services for patients with limited private transport options and where public transport is insufficient or inaccessible (for example, due to the cost or because patients have a disability).It is acknowledged that there are waiting times for public health care270, and that diverting some of the demand on the public health care system to the private system may reduce waiting times more broadly as well as enabling individuals to be seen more quickly.271 This may be particularly important for patients who may experience detrimental health impacts while waiting for services.

265 Robinson G, d’Abbs P, Bailie R & Togni S 2003, ‘Aboriginal Participation in Health Service Delivery: Coordinated Care Trials in the Northern Territory of Australia’, International Journal of Services Technology and Management, vol. 5, pp. 45-62.266 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health,Sydney.267 Bailie R, Di D, Connors C, Weeramanthri T, Clark L, Dowden M, O’Donaghue L, Concon J, Thompson S, Clelland N, Nagel T, Gardner K & Brown A 2008, ‘Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project’, BMC Health Services Research, vol. 8, no. 184, pp. 1-7.268 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health,Sydney.269 Ah Kit J, Prideaux C, Harvey PW, Collins J, Battersby M, Mills PD & Dansie S 2003, ‘Chronic disease self-management in Aboriginal communities: Towards a sustainable program of care in rural communities’, Australian Journal of Primary Health, vol. 9, no. 2 & 3, pp 168-176270 Biggs A 2008, Background Note, Hospital waiting lists explained (online only) Parliament of Australia Social Policy Section, Commonwealth of Australia, Canberra. 271 Hurst J & Siciliani L 2003,’Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries,’ OECD Health Working Papers, OECD, France.






Transportation to health care services, whether public or private, is a key barrier to accessing services for many Aboriginal and Torres Strait Islander people.272 Aboriginal and Torres Strait Islander people are more likely than non-Aboriginal and Torres Strait Islander people to experience both limited access to private transport and to live in areas with limited access to public transport.273 Research shows that addressing transport as potential barrier within program and service planning, such as through setting aside funds to support transport to and from activities, can maximise the impact of funded activities.274 11.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving improved chronic disease management as a result of the activities of this measure may be thought of as a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

CCSS Program Increase in primary health care system capacity to provide coordinated care

Increase in coordinated, multidisciplinary care




Islander patients engage with the

services

Primary health care providers make referrals to Care

Coordinators

Care Coordinators have a connection to

a registered practice/s



Incentive

Figure 15: CCSS measure causal pathway model. Source: KPMG. 11.4 Reach and timeframesThe potential reach275 of the CCSS (B3b) measure is determined by a number of factors, most notably: the number of patients registered for PIP Indigenous Health Incentive, which

is linked to the number of primary health care practices eligible to refer patients (see section );

272 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.273 Currie G, Stanley J & Stanley J, eds. 2007, No Way To Go: Transport and Social Disadvantage in Australian Communities, Monash University ePress, Clayton, Victoria.274 Gui G & Lau Q. 2007. Quick Meals for Kooris: an evaluation, Aboriginal and Islander Health Worker Journal, vol.31, no. 4, pp. 20-22.275 The term ‘reach’ in this Report refers to the potential and actual penetration of the measure’s impact on the intended target group.









the number of the number of Care Coordinators and their proximity and connection to referring practices; and

the number of eligible Aboriginal and Torres Strait Islander patients (see section ) accessing eligible primary health care practices and referring GPs.

The number of PIP Indigenous Health Incentive registered patients (as of May 2010) was 2,927; however, no Care Coordinators had been recruited at this stage. The reach of the measure should be greatly enhanced as access to the PIP Indigenous Health Incentive and recruitment of Care Coordinators progresses. As an early result (two to four years), the CCSS (B3b) measure is expected to provide enhanced capacity to the primary health care system to improve coordination of patient care for Aboriginal and Torres Strait Islander patients with chronic conditions. It is anticipated that in this timeframe, patients will be provided with increased access to coordinated care and benefit from improved adherence to a care plan for chronic disease management. In the longer term (four years and beyond), the primary health care system is expected to have an increased and sustained capacity to provide coordinated, multidisciplinary care to Aboriginal and Torres Strait Islander patients. Patients are expected to achieve a sustained improvement in risk factors associated with chronic disease, representing improved chronic disease management that should lead to improved health outcomes. 11.5 Complementary activityVarious programs which provide care coordination exist outside of the ICDP, both within the mainstream and IHS sectors. For instance, this type of position has been championed by the Australian Primary Care Collaboratives276 and in New South Wales the Chronic Care Program provides similar services. Refer to Appendix D for more information on Policy Maps which identify these complementary activities in other jurisdictions.The CCSS (B3b) measure is related to a number of other measures within the ICDP, in particular the PIP Indigenous Health Incentive, through the requirement that CCSS patients are referred by a PIP Indigenous Health Incentive registered provider and the incentive for GPs to undertake care planning. Care Coordinators may also work collaboratively with other ICDP funded providers, such as Aboriginal and Torres Strait Islander Outreach Workers and Indigenous Health Project Officers, or Practice Managers recruited under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure.The CCSS (B3b) measure is linked to the ICDP measures that provide outreach services, and Supplementary Services funding can assist patients to attend specialist and allied health appointments, such as those delivered under the USOAP and MSOAP-ICD measures. Care Coordinators can also access chronic disease self management training provided under the Improving Indigenous Participation in Health Care through Chronic Disease Self Management (B4) measure.

276 Australian Primary Care Collaboratives n.d., The rise and rise of the chronic care coordinator, viewed April 2012.




http://www.apcc.org.au/sharing_ideas/virtual_tabletops/the-rise-and-rise-of-the-chronic-care-coordinator/



Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. 11.6 CCSS data sourcesEvaluation of this measure will be informed by a range of primary data sources such as consultation with primary health care providers, the health workforce survey and review of program documentation. Non-ICDP data sources include the Medicare Benefits Schedule (MBS) data and Health Performance Framework (HPF) data.MBS data will be utilised in year four (2012-13) to assess changes in Aboriginal and Torres Strait Islander patient access to allied health and specialist services. The Evaluation Framework277 identifies one indicator to measure the whole of Package which is directly relevant to this measure. This is: Self-reported access to health services, as reported in section 3.12 of the HPF.


Refer to Appendix F for further information about this indicator, including the original source. The evaluation will monitor and provide updates on these indicators as they become available.11.7 Year one progress Commencing in July 2009 and concluding in February 2010, the department consulted with stakeholder groups including the PIP Advisory Group, and allied health and nursing peak bodies for the development of program guidelines for the CCSS (B3b) measure. Program guidelines were finalised in April 2010.278

On 10 May 2010, implementation arrangements were approved by the Minister for Indigenous Health. By 30 June 2010, funding agreements were signed with eight State Based Organisations to manage CCSS (B3b) measure funds. No recruitment activities had commenced by the end of financial year 2009-10. Three performance indicators for this measure are included in the Commonwealth Implementation Plan: Number of Indigenous clients registered with a PIP practice for chronic

disease management. Number of care coordination services to Indigenous clients.279

Since recruitment had not commenced in the 2009-10 year, no care coordination services were delivered.

277 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.278 Australian Government Department of Health and Ageing 2010, Indigenous Chronic Disease Package Care Coordination and Supplementary Services, Program Guidelines, viewed September 2012.279 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.










The design of the measure relies on participation in the PIP Indigenous Health Incentive for referral of patients. It is unclear, at this point, whether this requirement might create inequitable access to Care Coordination in locations where there is limited access to PIP Indigenous Health Incentive registered practices. This will be a matter for further investigation during the evaluation. The 2009-10 expenditure on this measure was $1.08 million.






12. Improving Indigenous participation in health care through chronic disease self management

Improving Indigenous Participation in Health Care through Chronic Disease Self Management (B4) at a glanceICDP priority area: Primary health care services that deliver.The issue being addressed: Aboriginal and Torres Strait Islander people have a higher prevalence of chronic disease than other Australians and are more likely to have multiple and/or complex health care needs that require active management. Given that they often also have limited access to primary health care for various reasons; effective self management can help to reduce the impact of chronic disease within existing constraints.The ICDP solution: This measure provides training in Chronic Disease Self Management (CDSM) for health care professionals to support their ability to deliver self management sessions to Aboriginal and Torres Strait Islander patients with chronic conditions. The supporting evidence: CDSM skills can improve health-related behaviours among Aboriginal and Torres Strait Islander people, and can delay progression of chronic disease. To be effective, self management programs must be delivered by skilled health care professionals, be culturally appropriate to Aboriginal and Torres Strait Islander patients, and be followed up with significant ongoing and personalised support. The central causal pathway: This measure aims to result in sustained improvements in relevant chronic disease clinical indicators. In order to achieve this outcome, the measure relies on health professionals trained in CDSM to deliver effective self management sessions to Aboriginal and Torres Strait Islander patients. In turn, patients can apply chronic disease self management to improve their own health. Reach: The reach of this measure is determined by the number and location of health care professionals who have received CDSM training, and the number of Aboriginal and Torres Strait Islander patients who receive CDSM sessions from these trained providers. Timeframes: It is expected that within two to four years, health care professionals trained in CDSM will be competent in delivering effective CDSM sessions, and patients are expected to be self managing their chronic diseases more effectively. Primary health care practices participating in the measure should be supporting the implementation of a self management approach to care. Within four years, it is anticipated that more participating patients will experience clinical improvements and that these impacts should be sustained. Year one progress: In the first year of implementation Flinders University was contracted to provide the CDSM training program, and training commenced in April 2010.






12.1 Design of the Improving Indigenous Participation in Health Care through Chronic Disease Self Management (B4) measure (also referred to as the Chronic Disease Self Management measure)

This measure involves delivery of CDSM training to primary health care workers. Training is provided through the Flinders University Closing the Gap ProgramTM

and the training is referred to as ‘Chronic Condition Self-Management.’ At a national level, the department has set a target for 400 health care professionals to receive the training.Training is available to primary health care workers including AHWs, GPs, registered nurses, Care Coordinators and allied health professionals who deliver health services to Aboriginal and Torres Strait Islander people with chronic disease. The training provides participants with the knowledge and skills to teach patients how to become active in the management of their own condition. Flinders University has developed CDSM training by adapting their mainstream training program to suit the Aboriginal and Torres Strait Islander cultural context. The expanded program includes cultural competency and a ‘yarning’ approach based on Narrative Therapy principles. The program has also been adapted to take into account the varying needs of different primary health care staff and diverse contexts for implementation, such as urban and remote settings. The training workshop teaches the principles of chronic disease support, and involves the use of assessment tools through which to identify issues, formulate an individual care plan and undertake patient monitoring and review. The training is expected to range from one and a half days (for GPs and practice nurses) to four days for AHWs and allied health professionals who deliver health services to Aboriginal and Torres Strait Islander people. The training is delivered at locations across Australia in a workshop format. Flinders University is responsible for piloting the training program and recruiting primary health care staff to participate in the program. Primary health care staff learn to use the following set of assessment tools for patients in the CDSM training. The Partners in Health (PIH) Scale – a tool completed by the patient which

measures their knowledge and understanding of their condition and current self management capacity.

The Cue and Response Interview (CRI) – this is an adjunct to the PIH, and is a set of open-ended questions to be used by the health professional to explore patient responses to the PIH in more depth.

The Problems and Goals Assessment (PGA) – this can be used separately from the above tools, or in addition to them. The PGA aims to identify problems from the patient perspective and helps the patient identify goals to address these problems.

As a part of the training program, CDSM training participants are required to complete a care plan with a volunteer patient. After the workshop, training participants must complete two care plans with their own patients in order to complete the program.






Training also includes post-workshop follow up mentoring in order to ensure that practitioners are supported to integrate the skills into their health service practice. Follow up may be delivered through face-to-face, telephone and email support to individual practitioners, small group sessions, and/or practitioner shadowing. Follow up may be provided at the participants' workplaces or at Flinders University. Participants who complete the program will receive a certificate that includes three Vocational Education and Training competencies in Chronic Disease Self Management that can be credited to the Health Care Certificate IV.

Application of CDSM within the health service setting requires a number of elements280: an initial care plan through consultation between the health care provider and

the patient to establish the patient’s health goals or actions, using the Flinders tools outlined above;

following up on the care plan agreement with five sessions in a 12 month period; and

recording and checking the health profile of the patient at least once within the 12 month period.

Beyond this basic level of competency, this measure also provides for a higher level of self management training at a ‘trainer’ level for some participants. Trainers will be available as training resources at the health services where they are located, and are also expected to act as change agents who can support the philosophy and practice of chronic disease self management. Critical to the success of this measure is the extent to which trained workers have the capacity to provide their patients with CDSM and have the support from their organisation to do so. Trained workers may be constrained by the day to day pressures of their job and may be constrained by limited access to other support services that are required to implement the care plan.This measure has also provided co-funding for a special CDSM project in remote Western Australia, where the Puntukurnu Aboriginal Medical Service will run a special project to train staff at five IHSs in the Pilbara and Kimberley regions. In this project, using a ‘train the trainer’ approach, Flinders University will provide CDSM training for staff of the Puntukurnu Aboriginal Medical Service which has been tailored to the remote context. These staff will then deliver self management training sessions to 1600 patients, and the outcomes will be subject to a separate evaluation.281 This project runs until June 2013. The department funded this project as a means to trial and support the application of self management training in remote settings.

280 Flinders University Human Behaviour and Health Research Unit n.d., Implementing Flinders Chronic Condition Self Management care planning in health service practice, Flinders University, Adelaide.281 The project is supported by an evaluation conducted by the University of Western Australia with in-kind sponsorship from BHP Billiton.






The total budget for this measure for the duration of the ICDP (from 2009-10 to 2012-13) is $18.56 million.

Stakeholders

The stakeholders of this measure include internal and external parties at local/community, regional, jurisdictional and national levels. Table 16 below provides an overview of the key stakeholder groups and their roles in relation to this measure.Table 16: Key stakeholders and roles in relation to the Chronic Disease Self Management (B4) measure.282

Stakeholder Role in Chronic Disease Self Management (B4) measure


Contract management of Flinders University and Puntukurnu Aboriginal Medical ServicePerformance monitoring of progress on implementation of the measure

Flinders University

Contractor responsible to provide CDSM training to up to 400 primary health care staff, and staff in the Puntukurnu Aboriginal Remote Project

Health care providers

Participate in CDSM training

Puntukurnu Aboriginal Medical Service

Run the Puntukurnu Aboriginal Remote Project to provide CDSM training to staff at five Indigenous Health Services in remote Western Australia


Receive CDSM sessions from primary health care workers trained in CDSM


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).283 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Chronic Disease Self Management (B4) measure. Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The measure supports the core aims and targets of Closing the Gap given its

focus on chronic disease management. The specific expected contribution is increased capacity for Aboriginal and Torres Strait Islander people to self









manage their chronic disease and therefore achieve improved health outcomes.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. Flinders University worked with Aboriginal and Torres Strait Islander people in

the trial of earlier versions of the program to tailor the pre-existing mainstream CDSM for this population.

Puntukurnu Aboriginal Medical Service is separately contracted by the department to be trained by Flinders University to deliver the program in remote communities.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The Chronic Disease Self Management measure is funded over the first four

years – 2009-10 to 2012-13. Flinders University is contracted to train primary health care workers who, once trained, are expected to have the capacity to sustain their knowledge and skills in self management.

There is currently no explicit strategy to deal with staff turnover and thus how to sustain the capacity that is expected to be built into the system. The sustainability of the measure will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. Flinders adapted the CDSM training from the mainstream CDSM program to

suit the Aboriginal and Torres Strait Islander context. Further, a special project is being delivered through a small number of remote

IHSs, which is being further tailored to primary health care workers working in this environment.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. Integration of this measure with other ICDP measures and other initiatives is

not currently apparent; however, there are opportunities for integration with other ICDP measures that Flinders and the department could explore.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. Flinders University is subjected to standard contract performance reporting

requirements of the department. The Chronic Disease Self Management measure is included in two ICDP

evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.






12.2 Rationale and supporting evidenceAboriginal and Torres Strait Islander people have a higher prevalence of chronic disease than other Australians and are more likely to have multiple and/or complex health care needs.284 The Chronic Disease Self Management (B4) measure presupposes that supporting Aboriginal and Torres Strait Islander people with chronic disease to enhance their understanding of their health and to self manage their health will help improve overall outcomes and reduce the negative impacts of chronic disease such as avoidable hospital admissions.The measure also responds to evidence that access to affordable chronic disease self management programs is a barrier to good health outcomes for Aboriginal and Torres Strait Islander people.285

Evidence related to self management of chronic disease

Evidence suggests that self management can delay the progression of chronic disease where significant ongoing, personalised support is provided.286 Effective chronic disease self management is associated with increased access to services, improved knowledge and understanding of chronic conditions, improved health and wellbeing and patient satisfaction.287 Providing education about chronic disease management, and goal setting and monitoring processes – particularly when these processes are culturally appropriate – has been shown to lead to improved self management skills and health-related behaviours amongst Aboriginal and Torres Strait Islander people.288 Chronic disease self management can also have a significant impact on community awareness of chronic diseases and an improvement in clinical processes.289

Meaningful participation by patients is considered essential to support effective chronic disease self management, and is more likely to lead to patients taking on

284 Steering Committee for the Review of Indigenous Service Provision 2007, Overcoming Indigenous Disadvantage Key Indicators 2007, Report, Commonwealth of Australia, Canberra.285 Lorig K & Holman H 2004, ‘Patient self-management: a key to effectiveness and efficiency in care of chronic disease’, Public Health Rep, 119(3). 286 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.287 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.288 Ah Kit J, Prideaux C, Harvey PW, Collins J, Battersby M, Mills PD & Dansie S 2003, ‘Chronic disease self-management in Aboriginal communities: Towards a sustainable program of care in rural communities’, Australian Journal of Primary Health, vol. 9, no. 2 & 3, pp 168-176.289 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.












greater responsibility for their own care.290 Additionally, involving family members in care is considered essential. 291

Research suggests that there are a number of factors influencing the effectiveness of programs aiming to support chronic disease self management. These include: providing effective training to health professionals to deliver high quality

chronic illness care; high levels of patient participation and engagement in care provision; applying tools tailored to the Aboriginal and Torres Strait Islander community

contexts; multidisciplinary approaches involving a range of service providers; and forging links between the chronic disease self management program and

other existing health promotion programs. 292,293,294,295,296

Research has shown that assisting patients to navigate the service system, and providing follow up support – both formal and informal – as relevant to patient needs, are important in supporting chronic disease self care.297 Research suggests that adaptation of resources and education materials for Aboriginal and Torres Strait Islander people may also support effective chronic disease self management. Such resources should contain plain English or use

290 McGowan P & Green LW 1995, ‘Arthritis Self-management in Native Populations of British Columbia: An Application of Health Promotion and Participatory Research Principles in Chronic Disease Control’, Canadian Journal on Ageing, vol. 14, no. S1, pp. 201-212.291 Burgess CP, Bailie RS, Connors CM, Chenhall RD, McDermott RA, O’Dea K, Gunabarra C, Matthews HL, Esterman AJ 2011, ‘Early identification and preventive care for elevated cardiovascular disease risk within a remote Australian Aboriginal primary health care service’, BMC Health Services Research, vol. 11, no. 3, p. 24.292 Burgess CP, Bailie RS, Connors CM, Chenhall RD, McDermott RA, O’Dea K, Gunabarra C, Matthews HL, Esterman AJ 2011, ‘Early identification and preventive care for elevated cardiovascular disease risk within a remote Australian Aboriginal primary health care service’, BMC Health Services Research, vol. 11, no. 3, p. 24.293 Burgess CP, Bailie RS, Connors CM, Chenhall RD, McDermott RA, O’Dea K, Gunabarra C, Matthews HL, Esterman AJ 2011, ‘Early identification and preventive care for elevated cardiovascular disease risk within a remote Australian Aboriginal primary health care service’, BMC Health Services Research, vol. 11, no. 3, p. 24.294 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.295 Wakerman J, Chalmers EM, Humphreys JS, Clarence CL, Bell AI, Larson A, Lyle D & Pashen DR 2005, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183, no. 10, pp. S64-S68.296 Health Inequalities Research Collaboration (HIRC) Primary Health Care (PHC) Network 2004, Action on Health Inequalities: Early Intervention and Chronic Condition Self - Management , viewed October 2011.297 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.




http://www.cphce.unsw.edu.au/CPHCEWeb.nsf/resources/CHETREreports1to5/$file/McDonald_J_(2004)_Action_on_Health_Inequalities_2.pdf



local language (particularly for remote audiences), and contain a high proportion of culturally-specific visual information.298,299,300

Evidence related to effective training approaches

Ongoing training and education for health providers in chronic disease self management is considered essential to support success.301,302 Health care providers should have a strong understanding of and skills in prevention approaches, management and legal and ethical requirements.303 To be most effective, training should be supported by strong organisational commitment to implement new approaches and practices.304 Self management training for health care workers should be geographically accessible and should account for the diverse learning needs, roles and backgrounds of workers in the Aboriginal and Torres Strait Islander health sector, specifically Aboriginal Health Workers.305 12.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving improved chronic disease self management capacity for Aboriginal and Torres Strait Islander people as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this

298 Sutherland A & Billimoria B 2011, ‘Aboriginal and Torres Strait Islander continence training in rural and remote Australia’, conference paper presented at the 11th National Rural Health Conference, March 2011. 299 Clifford A, Jackson Pulver L, Richmond R, Shakeshaft A & Ivers R 2010, ‘Brief intervention resource kits for Indigenous Australians: generally evidence-based, but missing important components’, Australian and New Zealand Journal of Public Health, vol. 34, no. S1, pp. s80-s86.300 Sutherland A & Billimoria B 2011, ‘Aboriginal and Torres Strait Islander continence training in rural and remote Australia’, conference paper presented at the 11th National Rural Health Conference, March 2011. 301 Health Inequalities Research Collaboration (HIRC) Primary Health Care (PHC) Network 2004, Action on Health Inequalities: Early Intervention and Chronic Condition Self - Management , viewed October 2011.302 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol. 6, no. 606, pp.1-15.303 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol. 6, no. 606, pp.1-15.304 Martin ME & Reath JS 2011, ‘General practice training in Aboriginal and Torres Strait Islander Health’, Medical Journal of Australia, vol. 194, no. 1, pp S67-S70.305 Sutherland A & Billimoria B 2011, ‘Aboriginal and Torres Strait Islander continence training in rural and remote Australia’, conference paper presented at the 11th National Rural Health Conference, March 2011.




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measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Chronic Disease Self Management measure

Health care professionals have capability to deliver

CDSM sessions to Aboriginal and Torres Strait

Islander patients

Improvements in patient’s self management of their

chronic disease(s)

Improvements in relevant chronic disease clinical

indicators

Aboriginal and Torres Strait Islander patients have adequate supports

to self manage

Primary health care practices support staff to deliver CDSM and to view patients as

partners


Islander patients are selected to receive

CDSM session


have capability and willingness to self manage

CDSM training is appropriate and

effective

Figure 16: Chronic Disease Self Management measure causal model. Source: KPMG.12.4 Reach and timeframesThe potential reach306 of the measure will be determined by factors including the number and location of health care professionals who have received CDSM training, and the number of Aboriginal and Torres Strait Islander patients who receive CDSM sessions from these trained providers. In 2009-10 the target number of workers to receive training was 41, however this was not achieved. As an early result (two to four years), this measure is expected to provide trained health workers with the knowledge and skills to effectively deliver chronic disease self management sessions to Aboriginal and Torres Strait Islander patients. In turn, it is anticipated that Aboriginal and Torres Strait Islander chronic disease patients will develop increased knowledge and skills in managing chronic disease, and will apply these to manage their own conditions. In the longer term (four years and longer), at the system level, the health workforce is expected to have increased and sustained capacity to deliver CDSM training to Aboriginal and Torres Strait Islander patients. At an individual level, it is anticipated that Aboriginal and Torres Strait Islander people trained in CDSM will have an increased and sustained reduction in the incidence and prevalence of relevant chronic disease clinical indictors. 12.5 Complementary activityPatient self management has been identified as an element of an enhanced primary health care system in Australia.307 A number of mainstream, national and state and territory initiatives are also working towards improving patient







involvement in the care of their own chronic disease. Some approaches are directed particularly to the Aboriginal and Torres Strait Islander population. Appendix B provides Policy Maps which identifies these complementary activities. Within the ICDP, there are no operational links between this measure and other ICDP measures. There are, however, natural links that could enhance implementation and outcomes, including: PIP Indigenous Health Incentive (B3a) measure: Staff from General Practices

which sign up for the PIP Indigenous Health Incentive and then subsequently register patients and pursue Tier 1 and Tier 2 outcome payments are potential ‘recruits’ for this measure. By registering under this measure, these practices have expressed an interest in and commitment to improving chronic disease management for Aboriginal and Torres Strait Islander people, and thus would potentially benefit from participating in the self management training program.

Care Coordinator and Supplementary Services Program (B3b) measure: Care Coordinators working with Aboriginal and Torres Strait Islander patients to support them in meeting their care plan would potentially benefit from CDSM training. Such training would enable them to empower their patients to understand and manage their own conditions, lessening their reliance on the Care Coordinators and allowing the workers to take on a larger client load.

Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measures: the literature cited earlier refers to a number of factors that are critical to the effectiveness of self management including follow up support to both patients and to the trained health workers, and coordination with other health promotion activities. The workforce recruited under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure (in IHSs) and under the Improving Access to Mainstream Primary Care (C3) measure (in Divisions of General Practice) are potential mechanisms to support and coordinate the implementation of self management with other related activities (ICDP, jurisdiction Closing the Gap activities and other Commonwealth-funded non-ICDP activities).

Clinical Practice and Decision Support Guidelines (C5) measure: part of the training of primary health care workers in self management could include reference to the web-based application being developed as part of the Clinical Practice and Decision Support Guidelines (C5) measure. Conversely, CDSM resource materials being developed by or used by Flinders University are potential content for the web-based application.

Refer to Appendix C for more information on the key synergies between the different measures of the ICDP.

307 Department of Health and Ageing 2009, Primary Health Care Reform in Australia, DoHA, Canberra.






12.6 Chronic Disease Self Management data sourcesEvaluation of this measure will be informed by primary data sources such as consultation with stakeholders, surveys of organisations and the health workforce, and program documentation. Other potential data sources will be explored throughout the evaluation. Collection of information about Aboriginal and Torres Strait Islander people receiving chronic disease self management is likely to be challenging. 12.7 Year one progressTwo performance indicators for this measure are included in the Commonwealth Implementation Plan: Number of workers provided with chronic disease self management support

training. Number of participants in chronic disease self management sessions or

activities.308

In 2009-10 Flinders University was contracted to provide CDSM training, with a target to provide training to 41 primary health care workers in this first year. Training commenced in April 2010.309 While the exact number of 2009-10 trainees is unknown, Flinders University was unable to meet its first year’s training target.310 Information about the number of participants in chronic disease self management sessions or activities was not available. The Puntukurnu Aboriginal Remote Project did not commence until 2010-11. In 2009-10, the expenditure on the measure was $1.16 million.

308 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.309 Based on information provided by the Department of Health and Ageing.310 Based on information provided by the Department of Health and Ageing.






13. Increasing Access to Specialist Care Increasing Access to Specialist Care (B5a) at a glanceICDP priority area: Primary health care services that deliver.The issue being addressed: Access to specialist services is essential for people suffering from chronic disease. Aboriginal and Torres Strait Islander people face particular barriers to accessing specialist medical services, such as financial cost, physical location and perceived lack of cultural sensitivity amongst providers. The ICDP solution: The Urban Specialist Outreach Assistance Program (USOAP) provides Aboriginal and Torres Strait Islander people with improved access to specialist services in culturally accessible urban locations. USOAP providers are required to undertake cultural awareness training in order to improve the cultural appropriateness of care delivery for Aboriginal and Torres Strait Islander patients. The supporting evidence: Research findings show that specialist outreach in urban settings can improve access to specialist services for Aboriginal and Torres Strait Islander people. The central causal pathway: USOAP aims to increase the capacity of health care specialists to provide accessible, appropriate outreach services to Aboriginal and Torres Strait Islander people. In order to achieve this outcome, the measure seeks to improve the cultural awareness of specialist service providers, and increase the volume and reach of outreach services. Reach: The reach of this measure is determined by the location and volume of specialist outreach service delivery, and the number of Aboriginal and Torres Strait Islander patients who access services through this measure.Timeframes: Within two to four years there is expected to be improved access to specialist care by Aboriginal and Torres Strait Islander patients. After four years, the health care system should continue to demonstrate increased and sustainable capacity to deliver specialist outreach services to Aboriginal and Torres Strait Islander people in urban locations. Year one progress: Activities in the first year of implementation included consultation, establishment of funding agreements, and commencement of service delivery in some jurisdictions.






13.1 Design of the Increasing Access to Specialist Care (B5a) measure (also referred to as USOAP or the USOAP measure)

The USOAP measure is composed of two core elements: specialist outreach services in the urban setting; and program support.

Specialist outreach services

USOAP provides culturally sensitive specialist outreach services for Aboriginal and Torres Strait Islander people within urban areas.311 In this context an outreach service refers to a medical specialist providing services in a setting which is familiar and culturally appropriate (such as an Indigenous health service or other primary health care setting). Patient services delivered as a part of USOAP focus on the management and treatment of chronic conditions.312

USOAP is being implemented in all jurisdictions across Australia, with the exception of the Northern Territory which has no areas classified as urban. The department has made fund holder arrangements with rural workforce agencies to administer the delivery of specialist outreach services (with the exception of Queensland where the fund holder is General Practice Queensland). These fund holders have been previously engaged in the delivery of the mainstream Medical Specialist Outreach Assistance Program (MSOAP) offered by the department, as well as the ICDP expansion of MSOAP through the MSOAP – Indigenous Chronic Disease (MSOAP-ICD) (B5b) measure.313

USOAP fund holders are responsible for: service planning; identifying and contracting specialists to provide urban outreach services; and making arrangements with suitable host organisations for service delivery. Host organisations may include IHSs or other suitable community facilities. Fund holders are also responsible for: ensuring that participating specialists receive cultural awareness training; monitoring service delivery; and reporting to the department. Fund holder reporting occurs through a schedule of progress reports, income and expenditure statements, and financial reports. Fund holders are required to collect and provide data on program service delivery to the department, including the314: total number of Aboriginal and Torres Strait Islander patients receiving

specialist services; total number of services provided; and311 Remoteness Areas 1 and 2 within the Australian Standard Geographical Classification.312 Department of Health and Ageing 2010, Closing the Gap, Increasing Specialist Follow up Care, Urban Specialist Outreach Assistance Program, Program Funding Guidelines, DoHA, Canberra.313Department of Health and Ageing 2009, Medical Specialist Outreach Assistance Program (website), viewed September 2012.314 Department of Health and Ageing 2010, Closing the Gap, Increasing Specialist Follow up Care, Urban Specialist Outreach Assistance Program, Program Funding Guidelines, DoHA, Canberra.




http://www.health.gov.au/internet/main/publishing.nsf/content/ruralhealth-services-msoap



types of speciality services supported.Funds under this measure can be applied to: remuneration for specialists; absence from practice allowance; backfilling allowance for salaried specialists; travel and incidental costs for accompanying support staff; some administrative support; facility fees; travel costs; accommodation costs; and equipment lease. Specialists providing outreach services are expected to bill for clinical service delivery though the Medicare Benefits Schedule (MBS), and are encouraged to bulk bill. USOAP allows an extra funding provision for cases “where there are significant concerns about the ability to claim on Medicare”315, due to issues such as patients not carrying Medicare cards or not attending scheduled appointments. Additional funds may be available to address these instances, which are reviewed on a case by case basis. Specialists provide services from Outreach Service Host Organisations, as recommended by the Program Advisory Committees in each jurisdiction.

Program support

The USOAP measure includes two types of program support to guide the implementation of the measure: program guidelines and program advisory support. Program guidelines developed by the department have been provided to fund holders to guide contracting and related obligations.Advisory support is provided by Program Advisory Committees in each jurisdiction. These bodies may be shared with the MSOAP-ICD (B5b measure), but must include an additional urban representative for the USOAP. The Program Advisory Committees identify existing gaps in specialist service delivery, make recommendations to fund holders on the location and type of specialist services that should be provided through USOAP, and advise on ongoing adjustments to the measure. Fund holders develop an implementation plan which is endorsed by the Program Advisory Committee.The total budget for USOAP for the duration of the ICDP (from 2009-10 to 2012-13) is $7.801 million.

Stakeholders

The department consulted a range of stakeholders in the development and implementation of USOAP, including: the Practice Incentives Program (PIP) Advisory Group, a pre-existing advisory

group which provides advice on the PIP overall, as well as the PIP Indigenous Health Incentive (B3a) and CCSS Program (B3b) measures316;

Indigenous Health Partnership Forums (IHPFs) in each jurisdiction; Royal Australian College of Physicians; 315 Department of Health and Ageing 2010, Closing the Gap, Increasing Specialist Follow up Care, Urban Specialist Outreach Assistance Program, Program Funding Guidelines, DoHA, Canberra.316 See section for further information.






Committee of Presidents of Medical Colleges – Australian Indigenous Health Sub-Committee; and

Royal Australian and New Zealand College of Ophthalmologists.Fund holders are expected to establish a Program Advisory Committee for their jurisdiction within six weeks of execution of the funding agreement, and to provide the committee’s Terms of Reference to the department. Membership of the Program Advisory Committee must include representatives from Aboriginal and Torres Strait Islander health representative bodies, such as the relevant National Aboriginal Community Controlled Health Organisation (NACCHO) affiliate in each jurisdiction. Figure 17 below presents the governance structure for the USOAP measure.

Department of Health and Ageing

Fund holders Program Advisory Committee

Outreach Service Host Organisations Medical Specialists


Figure 17: Governance of the USOAP (B5a measure).317

Stakeholders for the USOAP measure include government, industry and community representatives, and range from the national to the community level. Table 17 below provides an overview of the key stakeholder groups and their roles in relation to the USOAP (B5a) measure. Table 17: Key stakeholders and roles.318

Stakeholder Role in USOAP (B5a) measureDepartment Central Office

Develop program designProvide oversight to Department State / Territory Offices (STOs)Coordinate national-level monitoring and reporting

317 Based on information provided by the Department of Health and Ageing. 318 Based on information provided by the Department of Health and Ageing.






Stakeholder Role in USOAP (B5a) measureDepartment State / Territory offices Manage fund holder contracts

Program Advisory Committees in each jurisdiction

Consult with IHPFsProvide fund holders with advice on service need, type and locations

Fund holders Contract with medical specialists to provide outreach servicesContract with host organisations as service delivery site for outreach servicesDevelop a program implementation planProvide progress and financial reports to the department

Outreach service host organisations

Provide facilities and administrative support for delivery of outreach specialist servicesSubmit service data to fund holder

Medical specialists Deliver outreach specialist servicesParticipate in cultural awareness and safety trainingSubmit service data to fund holder


Receive outreach specialist services


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).319 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to USOAP. Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The measure supports the core aims and targets of Closing the Gap by

increasing Aboriginal and Torres Strait Islander peoples’ access to specialist care, which is expected to improve management of chronic diseases.

Key considerations for locating USOAP services included the burden of disease and gaps in access to existing services, as well as consultation with IHPFs.









Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. USOAP Program Advisory Committees are required to include representatives

from Aboriginal and Torres Strait Islander health representative bodies such as NACCHO Affiliates in each jurisdiction. The Program Advisory Committees are required to consult regularly with IHPFs regarding program delivery.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. USOAP is funded over the first four years – 2009-10 to 2012-13. USOAP requires specialist providers to complete cultural awareness training,

with may result in changes to practice that can be sustained beyond the initial funding period.


Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. USOAP aims to ensure specialist outreach services are provided in culturally

sensitive primary health care settings. As per the funding agreements, it is the responsibility of fund holders to ensure that host organisations are aware of cultural issues relevant to Aboriginal and Torres Strait Islander patients.

All medical specialists and accompanying support staff must complete locally appropriate cultural awareness training.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. Departmental stakeholders consulted for the development of USOAP include

OATSIH, the Rural Health Services and Policy Branch, and relevant State and Territory Offices. Communication is ongoing to ensure coordination within other ICDP measures.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. As per the funding agreements, fund holders formally report on the

performance of USOAP to the department on a regular basis. In turn, fund holders have reporting agreements with service host organisations and specialists. Monitoring reporting includes a schedule of progress reports, income and expenditure statements, financial reports and program activity / service delivery.

This measure is included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.






13.2 Rationale and supporting evidenceAccess to specialist services can be essential for people suffering from chronic disease, with some chronic diseases (such as kidney disease) requiring frequent and ongoing access to specialists320, and others (such as heart disease) leading to acute or emergency episodes in the absence of specialist access.321

Research shows that access to specialist services by Aboriginal and Torres Strait Islander people is impacted by cost, transport restrictions or logistical issues with getting to appointments, the timing of specialist appointments, perceived cultural inappropriateness of mainstream specialist services and lack of access to interpreters.322,323

Evidence related to specialist outreach services

A Cochrane review undertaken in 2004 found evidence supporting the fact that specialist outreach in urban settings has improved access to specialist services for Aboriginal and Torres Strait Islander people324, a finding also supported by other research projects and reviews.325,326

Outreach has been shown to lead to improved clinical outcomes327, particularly where coupled with other changes to provision of care such as joint consultations, education sessions, care enhancements, delivering recovery interventions and use of printed or video materials.328,329 The effectiveness of 320 Hoy WE, Kondalsamy-Chennakesavan S, Scheppingen J,Sharma S & Katz I 2005, ‘A chronic disease outreach program for Aboriginal communities’, Kidney International, vol. 68, pp. S76-S82.321 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.322 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp 517-512. 323 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.324 Gruen R & Bailie R 2004, ‘Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science,’ Journal of Health Services Research &Policy, vol. 9, pp. S56-S62.325 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health, Sydney.326 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.327 Fedder DO, Chang RJ, Curry S & Nichols G 2003, ‘The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes, with or without hypertension’, Ethnicity and Disease, vol. 13, pp. 22-27.328 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.329 Gruen R & Bailie R 2004, ‘Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science,’ Journal of Health Services Research &Policy, vol. 9, pp. S56-S62.












outreach services has also been linked to community engagement by outreach programs or providers, promoting health and well being through health promotion activities, and activities to support individual disease self management and community governance capacity.330

In regards to benefits, outreach services can reduce the barriers associated with travelling to access services and increase access to services within appropriate timeframes.331,332,333 Provision of specialist services via outreach has also been shown to be more cost effective than traditional clinical care.334 To address the cultural barriers experienced by many Aboriginal and Torres Strait Islander people in accessing mainstream services, USOAP involves provision of cultural awareness training to all specialists involved. Studies on provision of primary health care to Aboriginal and Torres Strait Islander people note that improved cultural competency leads to significant improvements in care of patients with chronic disease.335,336 Cultural awareness training can be an effective mechanism to improve the cultural competency of mainstream health services.337

Evidence related to program supports

The use of expert advisory forums and groups to guide the design and implementation of programs is a standard element of many government funded programs. There is evidence to suggest the common functions of these groups such as monitoring, evaluation and review of programs, facilitating communication between parties and coordination of existing human, financial

330 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.331 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp. 517-512. 332 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.333 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.334 Fedder DO, Chang RJ, Curry S & Nichols G 2003, ‘The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes, with or without hypertension’, Ethnicity and Disease, vol. 13, pp. 22-27.335 Lawrence M 2009, Improving the Patient Journey: Achieving Positive Outcomes for Remote Aboriginal Cardiac Patients, Cooperative Research Centre for Aboriginal Health, Darwin.336 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol 6, no. 606, pp.1-15.337 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and Overcoming the Barriers to Aboriginal Access to General Practitioner Services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, pp. 196-201.









and physical resources contributes to effective programs.338,339 Research also suggests that the input of Aboriginal and Torres Strait Islander people into program design and delivery is key to support success.340,341,342

13.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving improved health outcomes associated with better access to specialist care as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Aboriginal and Torres Strait Islander patients engage with USOAP

services


receive referrals to USOAP services

Service delivery sites are appropriate and

accessible

Outreach services respond to identified community health

needs

USOAP measure

Increase in care providers' cultural awareness

Increase in urban health system capacity to provide

culturally appropriate specialist outreach services

for chronic disease management

Improvement in patients’ access to a range of

culturally appropriate specialist outreach services

for chronic disease management


and skills



Recruitment and retention of outreach

service providers

Cultural awareness training is appropriate

and effective

338 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.339 Wakerman J, Chalmers EM, Humphreys JS, Clarence CL, Bell AI, Larson A, Lyle D & Pashen DR 2005, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183, no. 10, pp. S64-S68.340 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.341 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health, Sydney.342 Griew R 2008, The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.






Figure 18: USOAP measure causal model. Source: KPMG. 13.4 Reach and timeframesThe potential reach343 of the measure will be determined by factors including the location and volume of specialist outreach service delivery, and the number of Aboriginal and Torres Strait Islander patients who receive services through this measure.As an early result (between two to four years), the USOAP measure is intended to result in greater access to, and increased utilisation of, culturally sensitive specialist health care services for Aboriginal and Torres Strait Islander people in urban areas. Within this timeframe, these specialist services should meet the identified needs of the local population, and reflect the USOAP program guidelines.In the medium term (four years and greater), the USOAP measure is expected to result in increased and sustainable capacity to deliver appropriate and accessible specialist outreach services to Aboriginal and Torres Strait Islander people in urban locations. 13.5 Complementary activityOutside of the ICDP, a number of mainstream, national and state and territory initiatives also support increasing Aboriginal and Torres Strait Islander access to specialist services in metro, rural and remote areas. Appendix B provides Policy Maps which identifies these complementary activities. Within the ICDP, USOAP complements the MSOAP-ICD (B5b) measure, which provides similar outreach services in rural and remote areas. The majority of fund holders are engaged in both measures. Funding to expedite access to specialist medical services under USOAP may be provided through the Supplementary Services funding pool of the Care Coordination and Supplementary Services Program (B3b) measure. Care Coordinators funded under the B3b measure may also assist patients to access USOAP services.USOAP is intended to be promoted and supported by the Aboriginal and Torres Strait Islander Outreach Worker (ATSIOW) workforce (funded under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Improving Access to Mainstream Primary Care (C3) measures). The role of the ATSIOWs includes assisting patients to access specialist services. Indigenous Health Project Officers (funded under the Improving Access to Mainstream Primary Care (C3) measure) may promote the measure to primary health care practices registered for the PIP Indigenous Health Incentive (B3a measure).Refer to Appendix C for more information on the key synergies between the different measures of the ICDP.







13.6 USOAP data sourcesEvaluation of this measure will be informed by a range of primary data sources such as consultation with stakeholders, for example, community members, providers, fund holders and outreach service hosts, the health workforce survey and review of program documentation.The Evaluation Framework344 identifies one indicator to measure the whole of Package which is directly relevant to this measure. This is: Self-reported access to health services, as reported in section 3.12 of the HPF.


Refer to Appendix F for further information about this indicator, including the original sources. The evaluation will monitor and provide updates on these indicators as they become available.13.7 Year one progressActivities undertaken for this measure in the first year of implementation (2009-10) included consultation, establishment of agreements with fund holders, and commencement of service delivery. Program guidelines were developed and finalised in March 2010 in consultation with key stakeholders including the College of Physicians, Committee of Presidents of Medical Colleges, PIP Advisory Group, and IHPFs. USOAP is being implemented in a staged approach across the jurisdictions. Funding agreements were established with four fund holders by the end of the 2009-10 financial year, as follows: New South Wales: Rural Doctors Network; Queensland: General Practice Queensland; Victoria: Rural Workforce Agency Victoria; and Western Australia: Rural Health West. The first USOAP services were delivered in New South Wales in May 2010.USOAP was allocated $0.612 million for 2009-10 and an additional $0.4 million was allocated to the measure over the first year. . This additional funding was used to expand the implementation of the USOAP measure in the first year to include Victoria. All allocated funds were expended in 2009-10. While still in the early stages of specialist recruitment in the first year of implementation (2009-10), information provided by the department345 indicates that it was proving challenging for fund holders to recruit specialist outreach providers. Contributing factors included: the geographical overlap between the USOAP (B5a) and MSOAP-ICD (B5b)

measures. Both measures include Remoteness Area 2 in their service delivery 344 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.345 Based on information provided by the Department of Health and Ageing.








zones, which has created competition for recruitment of specialists in these areas; and

fund holders are mostly rural workforce agencies who have had to expand their network into urban areas in order to recruit for specialist providers.

The Commonwealth Implementation Plan identifies one performance indicator for the USOAP measure346: Number of Indigenous clients receiving specialist and allied health care in

urban areas through this measure. This, along with other performance data for 2009-10, is reported in Table 18 below.Table 18: 2009-10 performance for USOAP (B5a) measure quantitative indicators.347

Indicator 2009-10 performanceNumber of specialists participating 1Services* provided, by type of service General PsychiatryNumber of services* per location provided by specialists

Data not available

Number of Aboriginal and Torres Strait Islander peoples receiving specialist care through this measure

5

*Note: Definition of a service within USOAP: a medical specialist visiting and providing a consultation or treatment to an individual patient at a location approved by the Commonwealth for the purpose of the program.

346 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.347 Based on information provided by the Department of Health and Ageing.






14. Increasing Access to Specialist and Multidisciplinary Team Care

Increasing Access to Specialist and Multidisciplinary Team Care measure (B5b) at a glanceICDP priority area: Primary health care services that deliver.The issue being addressed: Access to specialist and allied health services is essential for people suffering from chronic disease. Aboriginal and Torres Strait Islander people in rural and remote communities face particular barriers to accessing health services, including location of available services, financial and family impact of long distance travel, and perceived cultural inappropriateness amongst health care providers. The ICDP solution: The Medical Specialist Outreach Assistance Program - Indigenous Chronic Disease (MSOAP-ICD) provides Aboriginal and Torres Strait Islander people with improved access to multidisciplinary services (specialist medical and allied health) in culturally sensitive environments in rural and remote areas. The supporting evidence: While research on the impacts of rural and remote specialist outreach for Aboriginal and Torres Strait Islander people is somewhat limited, the available literature on such services in the mainstream context suggests that it can reduce the need for rural dwellers to travel, can improve access to care within appropriate timeframes, may be more cost effective than traditional clinical care, and may in some cases lead to improvements in clinical outcomes. The central causal pathway: The MSOAP-ICD measure aims to increase capacity to provide accessible, appropriate outreach specialist and allied health services to Aboriginal and Torres Strait Islander people in rural and remote areas. In order to achieve this outcome, the measure relies on increased cultural awareness of service providers, and increased capacity of outreach health services. Reach: The reach of this measure is determined by the location and volume of outreach service delivery, and the number of Aboriginal and Torres Strait Islander patients who receive services through this measure. Timeframes: Within two to four years, patients are expected to receive more coordinated care through specialist outreach. After four years, the health care system should continue to demonstrate increased and sustainable capacity to deliver specialist and allied health outreach services to Aboriginal and Torres Strait Islander people in rural and remote locations. The baseline year: 2009-10 activities for this measure included consultation, establishment of funding agreements, and commencement of service delivery in some jurisdictions.






14.1 Design of the Increasing Access to Specialist and Multidisciplinary Team Care (B5b) measure (also referred to as MSOAP-ICD or the MSOAP-ICD measure)

The MSOAP-ICD measure is an extension of the pre-existing mainstream MSOAP funded by the Australian Government, which was originally developed in 2000 to improve rural and remote communities’ access to medical specialist services. Funding was allocated through the ICDP to expand the core MSOAP in order to accommodate outreach by medical specialists and allied health care providers in rural and remote Aboriginal and Torres Strait Islander communities.The MSOAP-ICD measure is composed of two core elements: outreach services in rural and remote settings; and program support.The total budget for the MSOAP-ICD for the duration of the ICDP (from 2009-10 to 2012-13) is $50.37 million.

Outreach services

The department has made fund holder arrangements with nine public and private organisations to administer the delivery of the MSOAP-ICD services. MSOAP-ICD is available to locations classified as inner regional to very remote348, however it is intended that remote and very remote areas will be prioritised. Funds have been distributed among state and territory jurisdictions based on the size of the Aboriginal and Torres Strait Islander population in regional and remote areas. MSOAP-ICD services are provided in priority locations, as recommended by the MSOAP-ICD Advisory Forum within each jurisdiction. Fund holders are responsible for identifying and contracting suitable health care professionals (specialists and allied health care professionals) in order to meet community needs. Needs are identified in the annual plan developed by the jurisdiction’s MSOAP-ICD Advisory Forum. Fund holders also ensure that participating health care professionals receive cultural awareness training, which is a mandatory requirement within the department’s funding agreement. Specialists and allied health care professionals provide patient services in priority locations on site at host organisations. Host organisations may include IHSs or other suitable community facilities that promote accessibility and cultural sensitivity for Aboriginal and Torres Strait Islander patients in rural and remote areas. All MSOAP-ICD services must be delivered by appropriately trained, qualified, registered and insured health professionals who have appropriate skills for the treatment and management of chronic diseases.349

Most outreach service providers - medical specialists, general practitioners and allied health professionals - are remunerated through claims against the Medicare Benefits Schedule (MBS). Other provisions are available where health 348 Remoteness Areas 2 to 5 with the Australian Standard Geographical Classification. 349 Department of Health and Ageing 2011, Medical specialist outreach assistance program, Indigenous chronic disease, 2009-10, Guidelines (June 2011) , viewed September 2012.




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professionals cannot claim against the MBS; in this case, the provider is paid an hourly rate appropriate to the state or territory. Additional financial support at sessional rates may be available to health care providers in circumstances where the MBS payments are not assured, for example due to patients not attending scheduled appointments.350 MSOAP-ICD may also be indirectly supported by new positions funded under other ICDP measures, such as Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs)351,352 and Care Coordinators353 where these ICDP workers are supporting access to specialists and allied health services. Travel costs, accommodation, meals and equipment lease are also covered by MSOAP-ICD funding. In the case that fund holders do not use all the available funding for service delivery, they may fund reserve services identified in the approved annual services delivery plan with the remainder of the funds.

Program support

Two types of program supports guide the implementation of the MSOAP-ICD measure: program guidelines and program advisory. Program guidelines, developed by the department, have been provided to fund holders to guide contracting and related obligations.Advisory support is provided by MSOAP-ICD Advisory Forums in each jurisdiction; these bodies may be shared with the USOAP (B5a measure). The MSOAP-ICD Advisory Forums identify existing gaps in specialist service delivery, make recommendations to fund holders on the location and type of services that should be provided through MSOAP-ICD, and advise on ongoing adjustments to the measure. Fund holders must develop an implementation plan which is endorsed by the MSOAP-ICD Advisory Forums.The membership of the MSOAP-ICD Advisory Forums in each state and the Northern Territory include Aboriginal and Torres Strait Islander health representatives, representatives from allied health organisations, and in some cases, representatives from the Indigenous Health Partnership Forum (IHPF). The MSOAP-ICD Advisory Forum is expected to liaise closely with the IHPF in their jurisdiction.

Stakeholders

Stakeholders for the MSOAP-ICD measure include internal and external parties at local/community, regional, jurisdictional and national levels. Table 19 below provides an overview of the key stakeholder groups and their roles in relation to the MSOAP-ICD measure.

350 Department of Health and Ageing 2011, Medical specialist outreach assistance program, Indigenous chronic disease, 2009-10, Guidelines (June 2011) , viewed September 2012.351 Expanding the Outreach and Service Capacity of Indigenous Health Organisations measure.352 Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care measure.353 Supporting Primary Care Providers to Coordinate Chronic Disease Management – Care Coordination and Supplementary Services (CCSS) Program








Table 19: Key stakeholders and roles in relation to the MSOAP-ICD (B5b) measure.354

Stakeholder Role in MSOAP-ICD measureDepartment Central Office

Develop program designProvide oversight to Department State and Territory Offices (STOs)Coordinate national-level monitoring and reporting

Department State / Territory Offices Manage funding agreements in each jurisdiction

MSOAP-ICD Advisory Forum in each jurisdiction

Make recommendations on the location and type of services offered

Fund holders Contract with medical specialists and allied health professionals to provide outreach servicesContract with host organisations as service delivery sites for outreach servicesDevelop a program implementation planProvide progress and financial reports to the department

Host organisations Provide facilities and administrative support for delivery of outreach specialist and allied health services

Medical specialistsAllied health care providers

Deliver outreach health servicesParticipate in cultural awareness and safety training

Aboriginal and Torres Strait Islander patients in rural and remote locations

Receive outreach services


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).355 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to MSOAP-ICD.









Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The measure supports the core aims and targets of Closing the Gap given its

focus on chronic disease management through specialist and multidisciplinary care. The composition of multidisciplinary teams varies depending on the health care needs of the communities.

Services are reviewed annually by the MSOAP-ICD Advisory Forums to ensure that they remain a priority for the region in which they are delivered.

A range of flexible service delivery models are supported, depending on the needs of communities.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. The membership of MSOAP-ICD Advisory Forums in each state and the

Northern Territory include representatives from Aboriginal and Torres Strait Islander organisations. The MSOAP-ICD Advisory Forums liaise closely with the Indigenous Health Partnership Forum (IHPF) located in the jurisdiction.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. MSOAP-ICD is funded over the first four years – 2009-10 to 2012-13. MSOAP-ICD requires specialist providers to complete cultural awareness

training, which may result in changes to practice that can be sustained beyond the initial funding period.


Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. The MSOAP-ICD measure extends specialist and allied health services to

Aboriginal and Torres Strait Islander communities in regional and remote areas, with delivery through Indigenous Health Services and other community settings. It complements the USOAP measure which facilitates Aboriginal and Torres Strait Islander patient access to specialist health services in urban areas.

All health care providers delivering services through the MSOAP-ICD must take cultural awareness training prior to commencing service delivery.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. A range of departmental stakeholders have been engaged throughout the

development of MSOAP-ICD including OATSIH, the Rural Health Services and Policy Branch, and relevant State and Territory Offices. Communication is ongoing to ensure coordination within other ICDP measures.






Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. As per the funding agreements, fund holders formally report on the

performance of the MSOAP-ICD to the department on a regular basis. Monitoring and reporting includes a schedule of progress reports, income and expenditure statements, financial reports and program activity / service delivery. In turn, fund holders have reporting agreements with service host organisations and specialists.

MSOAP-ICD is included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

14.2 Rationale and supporting evidenceAccess to specialist services can be essential for people suffering from chronic disease for both ongoing and acute or emergency care.356,357 However, Aboriginal and Torres Strait Islander people in rural and remote communities face barriers to accessing specialist and allied health services, including physical location.358 Research shows that access to specialist and allied health services by Aboriginal and Torres Strait Islander people living in remote locations is impacted by a perceived cultural inappropriateness of mainstream specialist and allied health services, and other cultural barriers such as lack of access to interpreters.359,360

Evidence related to specialist outreach services

There is some literature on the benefits and impacts of rural and remote specialist outreach for Aboriginal and Torres Strait Islander people. However, as pointed out by a 2004 Cochrane review, it is acknowledged that research into this area is somewhat limited.361 Available research demonstrates that provision of specialist outreach to Aboriginal and Torres Strait Islander people in rural and remote locations can support increased access to services within appropriate timeframes, improve

356 Hoy WE, Kondalsamy-Chennakesavan S, Scheppingen J,Sharma S & Katz I 2005, ‘A chronic disease outreach program for Aboriginal communities, Kidney International’, vol. 68, pp. S76-S82.357 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.358 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.359 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp 517-512. 360 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp 517-512.361 Gruen R & Bailie R 2004, ‘Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science’, Journal of Health Services Research &Policy, vol. 9, pp. S56-S62.









access to specialist services362,363,364, and in some cases lead to improvements in clinical outcomes.365 Outreach services can reduce the need for rural dwellers to travel – a key barrier to accessing services.366 Provision of specialist services via outreach has also been shown to be more cost effective than traditional clinical care.367,368

In rural and remote settings in particular, outreach has been shown to have limited impact on the number of referrals made by primary health care providers, but has supported ‘opportunistic’ self-referrals as well as increased access to primary health care services369 and reductions in the use of hospital (inpatient and outpatient) facilities. One outreach program in west Arnhem Land showed increased access to services by vulnerable or at risk groups including children, the elderly and women.370 The effectiveness of outreach services and their impact on clinical outcomes may be increased when delivered in conjunction with other changes to provision of care (e.g., joint consultations, education sessions, use of printed or video materials)371,372, high levels of community engagement by outreach programs or providers, health promotion activities, and activities to support individual disease

362 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change. New South Wales Department of Health, Sydney.363 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.364 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.365 Fedder DO, Chang RJ, Curry S & Nichols G 2003, ‘The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes, with or without hypertension, Ethnicity and Disease’, vol. 13, pp. 22-27.366 Gruen R, Bailie R, Wang Z, Heard S & O’Rourke I 2006, ‘Specialist outreach to isolated and disadvantaged communities: a population-based study’, The Lancet, vol. 368, no. 9530, pp. 130-138.367 Fedder DO, Chang RJ, Curry S & Nichols G 2003, ‘The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes, with or without hypertension, Ethnicity and Disease’, vol. 13, pp. 22-27.368 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp 517-512.369 Gruen R & Baillie R 2000, Evaluation of the Specialist Outreach Service in the top end of the Northern Territory , viewed October 2011.370 Gruen R & Bailie R 2004, ‘Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science’, Journal of Health Services Research &Policy, vol. 9, pp. S56-S62.371 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.372 Gruen R & Bailie R 2004, ‘Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science’, Journal of Health Services Research &Policy, vol. 9, pp. S56-S62.




http://www.aihw.gov.au/closingthegap/resources/qa.cfm?item_id=2370&ic_assessment_id=3201&group_type=BB&group_id=3&q=&coll=QA&perPage=all&detailList=SUMMARISE&start=118







self management and community governance capacity.373 However, this effectiveness can be compromised by challenges such as difficulties in recruiting and retaining Aboriginal Health Workers to be involved in programs, and inadequate patient recall and other systems within IHSs (from which care is frequently delivered).374

The MSOAP-ICD measure involves provision of cultural awareness training to all specialists involved. Cultural awareness training can be an effective way to support cultural competency in service provision375, address the cultural barriers experienced by many Aboriginal and Torres Strait Islander people in accessing mainstream services376,377, and thus improve the appropriateness and effectiveness of the care provided.


The MSOAP-ICD measure, like the USOAP (B5a) measure, involves development of program guidelines and advisory groups for program support. Relevant evidence shows that, where guidelines are used, the purpose and application of the guidelines should be made clear and guidelines should align with existing systems and ways of working.378,379

The use of advisory groups to guide the design and implementation of programs is a standard element of many government funded programs and there is evidence suggesting that program efficacy is associated with the common functions of these groups such as: monitoring, evaluation and review of programs; effective communication between parties involved in a project or initiative; and coordination between program resources.380,381 The input of

373 Tibby D, Corpus R & Walters DL 2010, ‘Establishment of an innovative specialist cardiac Indigenous outreach service in rural and remote Queensland’, Heart, Lung and Circulation, vol. 19, no. 5-6, pp. 361-366.374 Gruen R & Baillie R 2000, Evaluation of the Specialist Outreach Service in the top end of the Northern Territory , viewed October 2011.375 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and Overcoming the Barriers to Aboriginal Access to General Practitioner Services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, pp. 196-201. 376 Lawrence M 2009, the Patient Journey: Achieving Positive Outcomes for Remote Aboriginal Cardiac Patients, Cooperative Research Centre for Aboriginal Health, Darwin.377 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol 6, no. 606, pp.1-15.378 Weeramanthri T, Connors C, O’Leart S, Yamirr D, Wright J & Bell A 2002, ‘Chronic disease guidelines and the Indigenous Coordinated Care Trials Australian Health Review’, vol. 25, no. 2, pp1-6 and Pilla J 2002, ‘Giving support to disease guidelines’, Australian Health Review, vol. 25, no. 2, pp 7-10.379 McDermott R, Tulip F, Schmidt B & Sinha A 2003, ‘Sustaining better diabetes care in remote indigenous Australian communities’, British Medical Journal, vol. 327, no. 7412, pp. 428-430.380 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.








Aboriginal and Torres Strait Islander people into program design and delivery is key to support success382,383,384, particularly in rural and remote contexts.385

14.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving improved health outcomes associated with accesses to specialist and allied health care as a result of the activities of this measure, represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Outreach services respond to identified community health

needs


receive referrals to MSOAP-ICD services

Aboriginal and Torres Strait Islander patients engage with MSOAP-

ICD services

Service delivery sites are appropriate and

accessible

MSOAP-ICD measure

Increase in care providers' cultural awareness

Increase in regional and remote health system capacity to provide

culturally appropriate specialist and allied health

outreach services

Improvement in patients’ access to culturally

appropriate specialist and allied health outreach

services


and skills



Cultural awareness training is appropriate

and effective

Recruitment and retention of outreach

service providers

381 Wakerman J, Chalmers EM, Humphreys JS, Clarence CL, Bell AI, Larson A, Lyle D & Pashen DR 2005, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183, no. 10, pp. S64-S68.382 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.383 New South Wales Health 2004, Evaluation of the New South Wales Aboriginal Vascular Health Program 2000-2003: Building blocks for sustainable change, New South Wales Department of Health, Sydney.384 Griew R 2008, The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.385 Wakerman J, Chalmers EM, Humphreys JS, Clarence CL, Bell AI, Larson A, Lyle D & Pashen DR 2005, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183, no. 10, pp. S64-S68.






Figure 19: MSOAP-ICD causal model. Source: KPMG. 14.4 Reach and timeframesThe potential reach386 of the measure will be determined by factors including the locations and volume of outreach service delivery, and the number of Aboriginal and Torres Strait Islander patients who receive services through this measure. In 2009-10 the number of Aboriginal and Torres Strait Islander patients to receive services was 717. As an early result (from one to four years), the MSOAP-ICD measure is intended to result in greater access to and utilisation of culturally appropriate specialist and allied health care services for Aboriginal and Torres Strait Islander people in rural and remote areas. These services should meet the identified needs of the local population, and reflect the MSOAP-ICD program guidelines.As a medium term result (four years and greater), the MSOAP-ICD is expected to result in increased and sustainable capacity in the health care system to deliver appropriate and accessible specialist and multidisciplinary services to Aboriginal and Torres Strait Islander patients in rural and remote locations. 14.5 Complementary activityA number of mainstream, national and state and territory agendas are also working towards increasing access to specialists and allied health providers. For instance, Specialist Outreach Northern Territory (SONT) is funded by the Northern Territory Government to deliver health services in rural and remote areas. Appendix B provides Policy Maps which identify these complementary activities. Within ICDP, MSOAP-ICD is related to a number of other measures: USOAP (B5a measure): Together these measures are able to provide outreach

services to Aboriginal and Torres Strait Islander communities across the rural to urban continuum.

Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure and Improving Access to Mainstream Primary Care (C3) measure: Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs) from the C2 and C3 workforce may be involved in supporting patients to access the MSOAP-ICD. Indigenous Health Project Officers from the Improving Access to Mainstream Primary Care (C3) workforce may be involved in promoting MSOAP-ICD services among Divisions of General Practice.

Care Coordination and Supplementary Services (B3b measure): Care Coordinators from the CCSS Program may support patient access to MSOAP-ICD services.

Referrals to MSOAP-ICD may occur as a result of the PIP Indigenous Health Incentive (B3a).







Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. 14.6 MSOAP-ICD data sources Evaluation of this measure will be informed by a range of primary data sources such as consultation with stakeholders including community members, providers, fund holders and outreach service hosts; plus the health workforce survey and review of program documentation. The Evaluation Framework387 identifies one indicator to measure the whole of Package which is directly relevant to this measure. This is: Self-reported access to health services, as reported in section 3.12 of the HPF.


Refer to Appendix F for further information about this indicator, including the original sources. The evaluation will monitor and provide updates on these indicators as they become available.14.7 Year one progress MSOAP-ICD program guidelines were developed in 2009-10. The guidelines were based on those in place for the pre-existing mainstream MSOAP program and were refined though consultation with key stakeholders including the College of Physicians, Committee of Presidents of Medical Colleges, Practice Incentives Program (PIP) Advisory Group, and IHPFs. By the end of 2009-10, eight funding agreements had been established across six jurisdictions, as follows: Victoria: Rural Workforce Agency Victoria; Queensland: Queensland Health and General Practice Queensland; New South Wales: New South Wales Health and New South Wales Rural

Doctors; Network South Australia: Rural Doctors Workforce Agency; TAS: Department of Health and Human Services; and Western Australia: Rural Health West.These fund holders overlap, to some degree, with fund holders for the USOAP (B5a) measure (see chapter 13). Service delivery commenced in May 2010 in three states; Queensland (up to 42 services proposed), New South Wales (52 services proposed) and Western Australia (18 services proposed). The MSOAP-ICD measure faced some challenges in rollout which led to delays. Local implementation issues in the Northern Territory created further delays in









that jurisdiction.388 Such implementation issues will be further investigated in future stages of the evaluation. As noted in chapter 13, USOAP (B5a) and MSOAP-ICD (B5b) can both operate in Remoteness Area 2. While this creates potential for the two programs to compete for the same pool of providers, this was not identified as a challenge for the MSOAP-ICD program. One performance indicators for this measure are included in the Commonwealth Implementation Plan: Number of services provided by multidisciplinary health professional outreach

teams in rural and remote Indigenous communities.Table 20: Actual performance for MSOAP-ICD measure indicators, 2009-10.389

Performance indicator Actual performance 2009-10Type of specialist services provided through MSOAP-ICD

Respiratory physicianEndocrinologistNephrologistGeneral PractitionerCardiologistRenal PhysicianOphthalmologist

Type of allied health services provided by MSOAP-ICD

Spirometry InstructorAsthma Educator/NurseDiabetes EducatorDietician / NutritionistPhysiotherapistPodiatristNurse / Pre-dialysisAboriginal Health WorkerRegistrarRegistered NurseExercise Physiologist

Number of visits and the number of patients in total over a reporting period

129 visits for April-June 2010 reporting period, an average of 3.5 visits per location

Number of services provided by multidisciplinary health professional outreach teams in rural and remote Indigenous communities*

148

388 Based on information provided by the Department of Health and Ageing.389 Based on information provided by the Department of Health and Ageing.






Performance indicator Actual performance 2009-10Number of patients seen 865 patients (both Aboriginal and Torres Strait

Islander and non-Aboriginal and Torres Strait Islander people)390

Number of Aboriginal and Torres Strait Islander patients seen

717

*Note: Definition of a service within the MSOAP-ICD measure is: as a health professional (i.e., any individual medical specialist, GP and/or allied health), visiting and providing a medical consultation at an approved location.Only a small portion of the measure’s overall budget ($50.37 million for the first four years of the ICDP) was allocated and spent in 2009-10: $1.396 million.

390 Non-Aboriginal and Torres Strait Islander people may access MSOAP-ICD services if they live and work in a location where access to specialists is limited other than through MSOAP-ICD.






15. Workforce Support, Education and TrainingWorkforce Support, Education and Training (C1) measure at a glanceICDP priority area: Fixing the gaps and improving the patient journey.The issue being addressed: The Aboriginal and Torres Strait Islander Outreach Worker (ATSIOW) workforce employed in Indigenous health services (IHSs) and mainstream primary health care organisations require orientation and training in order to be equipped and supported in their roles. In addition, IHSs face challenges around recruitment and retention of GPs and nurses which can impact on organisational capacity to deliver effective chronic disease care to Aboriginal and Torres Strait Islander people. The ICDP solution: The Workforce Support, Education and Training (C1) measure provides orientation and training support for ATSIOWs. It also provides training posts in IHSs for GP registrars, professional development scholarships for fully qualified nurses and midwives working in IHSs, and scholarships for undergraduate nurses to enable them to complete clinical placements in IHSs. The supporting evidence: Research shows that orientation and training support is positively related to recruitment, retention and productivity of Aboriginal and Torres Strait Islander people in similar roles to ATSIOWs (such as Aboriginal Health Workers). Similarly, nursing professional development opportunities (afforded by scholarships) have been found to support nurse recruitment and retention in rural and remote locations. There is no established literature on the impact of GP registrar and nursing placements in IHSs. However, rural health workforce literature suggests a potentially positive relationship, including evidence that rural clinical placements influence the likelihood of a student choosing to pursue a career in rural medicine.

The central causal pathway: This measure aims to increase workforce capacity and capability to deliver primary health care services to Aboriginal and Torres Strait Islander people through: enhancing workforce capacity by providing and enhancing access to targeted

orientation and professional development opportunities; and increasing the current workforce and investing in the future workforce

through supporting opportunities for health professional to train and work in IHSs and remote locations.

Reach: The reach of the measure is determined by: the number and location of ATSIOW positions; the number and location of GP registrar training posts; the number of undergraduate nursing scholarships provided, and the location of the placements funded through these scholarships; and the number and location of nurses/midwives in IHSs who receive professional development scholarships. Timeframes: Within two to four years, the ATSIOW workforce is expected to be better equipped in their roles and more prepared to continue working in primary health care. GP registrars and undergraduate nurses are expected to have greater understanding of the health needs of Aboriginal and Torres Strait Islander people and, in increasing numbers, elect to work in IHSs upon






completion of training/schooling. Beyond four years, it is anticipated that the workforce overall will have sustained increased capacity and capability to deliver primary health care services to Aboriginal and Torres Strait Islander people. Year one progress: In (2009-10) a number of key activities were progressed including stakeholder consultations, the establishment of funding agreements, and the first round of placements for the GP registrar training posts. 15.1 Design of the Workforce Support, Education and Training (C1)

measureThe Workforce Support, Education and Training (C1) measure is composed of three distinct components: orientation and training support for Aboriginal and Torres Strait Islander

Outreach Workers (ATSIOWs); GP registrar training posts; and nursing scholarships and placements.The measure has a budget of $17.74 million across the first four years of the ICDP (2009-10 to 2012-13).

Orientation and training support for Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs)

ATSIOWs are entry-level positions that have been recruited under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measures. This measure supports the ATSIOW workforce by providing orientation, access to training, and networking opportunities through national conferences.The department has provided the National Aboriginal Community Controlled Health Organisation (NACCHO) affiliates in each state and territory with funding to develop and deliver ATSIOW orientation packages tailored to needs identified in each jurisdiction, and generally delivered over a one or two day workshop. Although national guidelines have not been provided for the contents of orientation packages, they generally consist of a number of modules that provide the ATSIOW workforce with background information on the Australian health workforce, relevant information about working in the health system, and an understanding of the ATSIOW service delivery role. Participating in orientation is mandatory for ATSIOWs, and is expected to be undertaken within six months of commencement in the position. The measure also includes provisions for ATSIOW training support. ATSIOWs have the opportunity to access nationally-accredited health-related competency training in the vocational education and training sector. Participation in training is optional and needs-based, as identified through consultation between the ATSIOW and their employer. Where training needs are identified, training funds can be accessed through the relevant NACCHO affiliate or SBO. The NACCHO affiliate or SBO submits training proposals directly to the department for funding. This process is flexible, and based on individual needs.






Networking and professional development opportunities are provided through national conferences held every two years and funded by the department. The purpose of the conferences is to encourage networking of the ATSIOW workforce and sharing of information between ATSIOWs.

GP registrar training posts

The department has provided funding to General Practice Education and Training Ltd (GPET) to increase the number of ‘Aboriginal and Torres Strait Islander Health Training Posts’ (ATSIHTP) within the Australian General Practice Training Program. The Workforce Support, Education and Training (C1) measure funding allows GPET to add 38 GP registrar placements annually to the 2008 baseline of 101 placements geared towards the IHS sector. The ATSIHTP may form one or more of the six placements that GP registrars are required to complete in order to qualify as a GP. Placements are available across a number of organisations, including community controlled and state or territory run IHSs; Advanced Rural Skills Post in Aboriginal health (outside of a hospital); Northern Territory Remote Registrar; and Paediatric Outreach Service (Cairns). The placements are available to GP registrars at all stages of fellowship training, and are located in metropolitan, rural and remote areas throughout Australia. Placements may begin in January or July each year. GPET funds seventeen regional training providers, who in turn liaise with accredited training posts for the placement of GP registrars.GP registrars provide health services during their placement, and gain exposure to the service delivery environment of the training post. Funding through this measure covers the salary of GPs, since service levels in the IHS sector may not provide adequate compensation through fee-for-service billing. Salaries are set by individual IHSs and vary across locations according to market factors. Salaries for Aboriginal and Torres Strait Islander Health Training Posts are higher than other training posts available through GPET.391

Nursing scholarships and placements

This component of the Workforce Support, Education and Training (C1) measure is administered by the Royal College of Nursing Australia (RCNA), and includes two types of nursing scholarships: scholarships to enable undergraduate nurses to do clinical nurse placements within IHSs; and professional development scholarships for fully qualified nurses and midwives working in IHSs. These scholarships are provided under the Nursing and Allied Health Scholarship and Support Scheme (NAHSSS) administered by the RCNA and with technical support from the NAHSSS Advisory Group. The measure funds 50 scholarships annually for undergraduate nurses to undertake clinical placements in IHSs. This placement program for IHSs is the first of its kind at a national level. Funds up to $11,000392 are provided to cover out-of-pocket costs for the student, as well as pay the host organisation to 391 Based on information provided by the Department of Health and Ageing. 392 Royal College of Nursing Australia n.d., Clinical Placement Scholarships for nursing students undertaking placement in Aboriginal Medical Services (website), viewed October 2011.




http://www.rcna.org.au/WCM/RCNA/Scholarships/Government/nahsss_cp_ams/rcna/scholarships/government/nahsss_clinical_placement-Aboriginal_medical_services.aspx

http://www.rcna.org.au/WCM/RCNA/Scholarships/Government/nahsss_cp_ams/rcna/scholarships/government/nahsss_clinical_placement-Aboriginal_medical_services.aspx



provide supervision. Student applicants are required to indicate how their studies relate to work in an IHS, and how their chosen course will benefit the health of Aboriginal and Torres Strait Islander people, as well as provide evidence that they have completed cultural awareness training. Clinical placements are promoted through the RCNA and nursing schools.The measure involves at least two rounds of applications for professional development scholarships for nurses and midwives working in IHSs. The first round was in May-June 2010 (during the Baseline Report period of the evaluation) and the second in August/October 2010. A total of 50 continuing professional development were available during these two rounds. For both types of scholarships, applicants are expected to have knowledge of contemporary issues, and an interest in contributing to improving Aboriginal and Torres Strait Islander health. Scholarship applicants who are of Aboriginal or Torres Strait Islander descent receive an additional five ranking points in the selection process.

Governance, leadership and strategy

A Workforce Training and Capacity Advisory Group provided advice on the design of the Workforce Support, Education and Training (C1) measure during the measure’s development stage. This Group consisted of representatives from within the department and other stakeholder groups including (but not limited to) NACCHO, the Australian Indigenous Doctors Association (AIDA), the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN), AGPN and Indigenous Allied Health Australia (IAHA), and was convened to provide expert advice on implementing the health workforce and training component of the ICDP.

Stakeholders

The stakeholders of this measure include internal and external parties at local/community, regional, jurisdictional and national levels. Table 21 below provides an overview of the key stakeholder groups and their roles in relation to the measure






Table 21: Key stakeholders and roles in relation to the Workforce Support, Education and Training (C1) measure.393

Stakeholder Role Category Role in the Workforce Support, Education and Training measure


Funding agreement Manages funding agreements with GPET, RCNA, NACCHO, and SBOsFunds national ATSIOW workshopsProvides oversight of Departmental State and Territory Offices

Department State / Territory Offices (STOs)

Funding agreementManage funding agreements with NACCHO affiliates

National Aboriginal and Torres Strait Islander Health-Registered Training Organisation National Network

ATSIOW professional development

Develops a needs analysis for ATSIOW orientation and training

NACCHO ATSIOW professional development

Arranges national ATSIOW workshops

NACCHO affiliates


Develop and deliver ATSIOW orientation to workforce employed under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Improving Access to Mainstream Primary Care (C3) measures






Stakeholder Role Category Role in the Workforce Support, Education and Training measure

ATSIOWs ATSIOW professional development

Participate in and provide feedback on orientation activitiesParticipate in national workshops

Divisions of General Practice/Medicare Locals


Host Improving Access to Mainstream Primary Care (C3) ATSIOW workforce



Host Improving Access to Mainstream Primary Care (C3) ATSIOW workforce

General Practice Education and Training Ltd.

GP registrar training posts Administers GP registrar training posts and placement funds

Regional training providers

GP registrar training posts Liaise with IHS sector for placement of GP registrars

IHSs GP registrar training posts Provide supervision and salary to GP registrars

GP registrars GP registrar training posts Apply and participate in Aboriginal and Torres Strait Islander Health Training Posts

Royal College of Nursing Australia


Administers nursing scholarships and placement funds

Nurses and midwives working in Indigenous health services


Apply for professional development funding and undertake professional development activities

Undergraduate nurses


Apply for clinical placement scholarships and undertake placement in the IHS sector


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap






National Indigenous Reform Agreement (NIRA).394 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Workforce Support, Education and Training (C1) measure. Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The measure expands and supports the primary health care workforce in the

IHS sector. Building the capacity of primary health care for serving the Aboriginal and Torres Strait Islander population is a priority within the Closing the Gap initiative.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. ATSIOW orientation is being developed and delivered through the NACCHO

affiliates. GP registrar and clinical nursing placements are hosted in the IHS sector. Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The measure is funded over the first four years – 2009-10 to 2012-13.

Continuity of the ATSIOW workforce, which is dependent on continued funding, will determine the need for ongoing support.

Both funding availability and continued uptake by GP registrars and nurses will determine the sustainability of the other components of this measure.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. This measure promotes access by increasing the number of GP registrars and

student nurses delivering services in IHSs. The measure also promotes access by supporting the development of

ATSIOWs, whose role is to promote health services and resources to community members.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. The measure involves collaboration by government with a wide range of

stakeholders, including government-funded entities such as (but not limited to) GPET, Divisions of General Practice/Medicare Locals, NACCHO and universities.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. The Workforce Support, Education and Training (C1) measure is included in

two ICDP evaluation projects – the Indigenous Chronic Disease Package









National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

Three sections of the Health Workforce Division are involved in monitoring and reporting on progress of the Workforce Support, Education and Training (C1) measure.

15.2 Rationale and supporting evidence The Workforce Support, Education and Training (C1) measure is based on the rationale that there is a need to support the participation of Aboriginal and Torres Strait Islander people in the health care workforce, and that there is a need to attract and retain GPs and nurses to the IHS sector. Improvements in these areas are expected to increase access to primary health care for Aboriginal and Torres Strait Islander people. Research shows that a lack of staff from their own cultures acts as a barrier to Aboriginal and Torres Strait Islander people accessing primary health care services.395 Presently, Aboriginal and Torres Strait Islander people constitute a small proportion of the Australian health care workforce. While Aboriginal and Torres Strait Islander people represent 2.3 per cent of the total Australian population (2006 census396), they make up only 0.2 per cent of the medical practitioner and 0.6 per cent of the nurse workforce.397 In addition, IHSs face challenges in filling staff vacancies, such as for Aboriginal Health Workers398, doctors and nurses399, particularly in outer regional and remote locations.400

Evidence related to orientation and training support for ATSIOWs

Given that the ATSIOW positions are newly developed, there is no direct evidence relevant to a discussion of orientation and training support for this workforce; however, literature on Aboriginal Health Workers (AHWs) is likely to have some relevance to the ATSIOW context.There is evidence that AHWs require education and training in order to support retention and sustainability of the workforce. Where orientation, education and

395 Hayman NE, White NE & Spurling GK 2009, ‘Improving Indigenous Patients’ access to mainstream health services: the Inala experience’, Medical Journal of Australia, vol. 190, no. 10, pp. 604-606.396 Australian Bureau of Statistics 2009, Experimental Estimates and Projections, Aboriginal and Torres Strait Islander Australians, 1991 to 2021. cat no. 3238.0, ABS, Canberra.397 Australian Institute of Health and Welfare 2010, Aboriginal and Torres Strait Islander health services report, 2008-09, OATSIH Services Reporting – key results, cat. no. IHW 31, AIHW, Canberra.398 Bailie R, Cunningham J, Robinson G, Dowden M, Stewart A, Connors C & Weeramanthri T 2008, ‘Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia's Northern Territory – use of the Chronic Care Model’, BMC Health Services Research, vol. 8, pp. 112.399 Lyle D & Kerr C 2001, ‘Building capacity in rural health’, New South Wales Public Health Bulletin, vol. 12, no. 6, pp. 159-161400 Australian Institute of Health and Welfare 2010, Aboriginal and Torres Strait Islander health services report, 2008-09, OATSIH Services Reporting – key results, cat. no. IHW 31, AIHW, Canberra.






preparation programs for Aboriginal Health Workers are inconsistent and/or non-ongoing, this can result in inadequate recruitment rates for AHWs as well as high turnover.401 Training and education activities are important to enhance the potential productivity and retention of the AHW workforce, while discontinuous or insufficient training represent barriers to providing better practice health care.402 Training for the workforce is also an effective way for health professionals in the IHS sector to share information, and support the development of networks and mechanisms to improve chronic disease management.403 Short training courses are more likely to be completed by workers than longer courses, but Hunter (2010) states that the most effective way to ensure participation is to design training that is “friendly” to the Aboriginal and Torres Strait Islander population, such as by providing more “support” (e.g., mentoring) and career counselling.404

Research highlights the importance of geographically accessible training for AHWs in rural and remote locations using a variety of teaching methods. In one study, participants reported that face-to-face training was the most beneficial as it enabled them to work in groups and learn from each other’s experiences. Unavoidable factors including the wet season, funerals and sorry business and ‘lore’ for men, may take precedence in the Aboriginal and Torres Strait Islander cultural context, and should be considered in the design and delivery of training programs in rural and remote locations.405

Evidence related to GP registrar training posts

GP registrar training posts are intended to address barriers to the recruitment of GPs to work in the IHS sector. Factors such as the location of many clinics in rural or remote areas406, and other difficulties once GPs are employed, such as issues with cross-cultural communication407, can present barriers. 401 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol. 6, no. 606, pp1-15.402 Si D, Bailie RS, Togni SJ, D'Abbs PHN & Robinson GW 2006, ‘Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis’, Medical Journal of Australia, vol. 185, no. 1, pp.40-45.403 Smith J, O’Dea K, McDermott R, Schmidt B & Connors C 2006, ‘Educating to improve population health outcomes in chronic disease: an innovative workforce initiative across remote, rural and Indigenous communities in northern Australia’, Rural and Remote Health (online), vol. 6, no. 606, pp1-15.404 Hunter BH 2010, Pathways for Indigenous school leavers to undertake training or gain employment, Resource Sheet no. 2, produced for Closing the Gap Clearinghouse, Australian Institute of Health and Welfare, Canberra & Australian Institute of Family Studies, Melbourne.405 Sutherland A & Billimoria B 2011, Aboriginal and Torres Strait Islander continence training in rural and remote Australia, Conference paper presented at the 11th National Rural Health Conference, March 2011. 406 Australian Bureau of Statistics 2009, Experimental Estimates and Projections, Aboriginal and Torres Strait Islander Australians, 1991 to 2021, cat. no. 3238.0, ABS, Canberra.407 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of






There is an absence of literature on GP placement in IHSs. However, the rural health literature offers some insight into the potential effectiveness of this measure in attracting GPs to IHSs. This research shows that medical students experiencing early and repeated rural exposure during training are more likely to practise in a rural location.408 In addition, rural clinical placements positively influence the likelihood of a student choosing to pursue a career in rural medicine, particularly if the placements are well coordinated, for an extended period of time, provide opportunities for interaction with local health professionals, and include opportunities to pursue further specialist training while working in a rural area after graduation.409

Evidence related to nursing scholarships and placements

The rural health literature again provides some insight into the impacts of nursing scholarships and placements. A study of undergraduate nursing students found that those undertaking a final year rural clinical placement were more likely to intend to seek work in a rural setting after graduation as compared to those who undertook a metropolitan placement. Staff support was cited as the main factor that would encourage students to return to a rural setting upon graduation. The lack of financial, accommodation and transport assistance was a major barrier to students undertaking clinical placements, particularly if they came from an urban background.410 Huntley (1995) surveyed 158 nurses working in rural and remote area hospitals, and found that employers’ recognition of the importance of continuing professional education was a significant factor contributing to retention. Conversely, inadequate access to continuing education, and employers’ lack of understanding of professional needs, were some of the main reasons cited for leaving, or intending to leave, rural employment.411 15.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving enhanced workforce and service system capacity as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this

Rural Health, vol. 10, no. 4, pp. 196-201.408 Dunbabin JS & Levitt L 2003, ‘Rural origin and rural medical exposure: their impact on the rural and remote medical workforce in Australia’, The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy , viewed October 2011.409 Henry JA, Edwards BJ & Crotty B 2009, ‘Why do medical graduates choose rural careers?’, Rural and Remote Health vol.9, viewed October 2011.410 Neill J & Taylor K 2002, ‘Undergraduate nursing students’ clinical experiences in rural and remote areas: recruitment implications’, The Australian Journal of Rural Health, vol. 10, no. 5, pp. 239-243.411 Huntley B 1995, ‘Factors influencing recruitment and retention: why RNs work in rural and remote area hospitals’, Australian Journal of Advanced Nursing, vol. 12, no. 2, pp. 14-19.




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measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

GPs and nurse trainees have

positive perception of their placement

experience

Benefits of work in IHSs outweighs costs to GPs and

nurses

Workforce Support, Education and Training

Increase in delivery of primary health care

services by GPs and nurses

Improved preparation and development of the

ATSIOW workforce to effectively carry out their

duties

Increase in health system capacity and capability to deliver primary health care services to Aboriginal and

Torres Strait Islander people

More ATSIOWs, GPs and nurses choose to sustain

their employment in Indigenous Health Services

GPs and nurses have greater understanding of

the health needs of Aboriginal and Torres Strait

Islander people

ATSIOWs feel supported and satisfied with their

roles

Nurses in IHSs have greater opportunities for

professional development

Nurses in IHSs feel supported and satisfied

with their roles

ATSIOW orientation is appropriate and

effective

Employers provide supportive work environments to

ATSIOWs

ATSIOW training is accessible and

relevant to work in health care sector

Figure 20: Workforce Support, Education and Training causal model. Source: KPMG. 15.4 Reach and timeframesThe potential reach412 of the measure will be determined by factors including: the number and location of ATSIOW positions; the number and location of GP registrar training posts; the number of undergraduate nursing scholarships provided, and the location of the placements funded through these scholarships; and the number and location of nurses/midwives in IHSs who receive professional development scholarships.As noted previously, at 2009-10 it was intended that: 38 additional GP registrar training posts would be available annually; 50 undergraduate nurse scholarships would be available annually; and 50 professional development scholarships would be made available across (at

least) two rounds across 2010-11.







Within the first two to four years, the Workforce Support, Education and Training (C1) measure is expected to yield a number of early results. ATSIOW orientation and training support is expected to result in ATSIOWs being better equipped to carry out their required role and to support continued work (retention) of ATSIOWs in primary health care assisting Aboriginal and Torres Strait Islander people. Within this same early timeframe, the GP registrar training posts are expected to increase the availability of GP services in the IHS sector. Placements will also increase GP registrars’ understanding of health issues impacting Aboriginal and Torres Strait Islander people. It is anticipated that GP registrars will increasingly elect to work in the IHS sector post-training.Similarly, nursing clinical placements provide the opportunity for nursing students to understand work in the IHS sector, and encourage them to work in this area upon completion of their education. Nurses who receive professional development scholarships are expected to have improved access to ongoing education, and therefore be supported to continue their work in IHSs. For all workers, the training and placements are also anticipated to be of value and benefit.As a medium term result (greater than four years), the measure overall is anticipated to lead to increased capacity and capability within IHSs and mainstream primary health care services to deliver services to Aboriginal and Torres Strait Islander patients. Other than numbers of GP registrar placements, nursing scholarships and nursing clinical placements, measurement of outcomes and changes associated with the measure will be largely dependent on collection of qualitative data, for example through the workforce survey, to be conducted as part of future evaluation activity. 15.5 Complementary activityA number of mainstream, national and state and territory agendas are also working towards increasing workforce support, education and training for the Aboriginal and Torres Strait Islander health workforce. Notably, Health Workforce Australia, an initiative of COAG, develops policy and programs for workforce planning and sustainability, including strategies for rural and remote areas. Refer to Appendix D for more information on Policy Maps which identify these complementary activities. Within the ICDP, the Workforce Support, Education and Training (C1) measure is related to a number of complementary activities. This measure is closely related to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measures, as the Workforce Support, Education and Training (C1) measure provides orientation and training opportunities to the ATSIOW workforce recruited under the C2 and C3 measures.






The orientation, training and education needs assessment for ATSIOWs and Healthy Lifestyle Workers (employed under the Helping Indigenous Australians Reduce their Risk of Chronic Disease (A2) measure) was developed concurrently by the Aboriginal and Torres Strait Islander Health Registered Training Organisation National Network, thereby also creating a link with the HLW measure. Finally, the aims of the Attracting More People to Work in Indigenous Health (C4) measure are complementary to the Workforce Support, Education and Training (C1) measure activities, particularly the GP registrar placement, and nursing scholarships and placements. However, the measures are not directly related operationally.Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. 15.6 Workforce Support, Education and Training data sources Evaluation of this measure will be informed by a range of primary data sources such as consultation with primary health care providers, community members and ICDP workers, the broader health workforce; organisational surveys; and review of program documentation. Available data on process indicators including: the number of nurse scholarships taken up, and the number of GP registrar training posts filled, will also be reported. With regard to the GP registrar placements: these are an extension to a pre-existing program, and it will not possible to distinguish the location of ICDP-funded placements from others.The Evaluation Framework413 identifies one indicator to measure the whole of Package which is directly relevant to this measure. This is: Self-reported access to health services, as reported in section 3.12 of the HPF.


Refer to Appendix F for further information about this indicator, including the original sources. The evaluation will monitor and provide updates on these indicators as they become available.15.7 Year one progress A needs analysis on ATSIOW training and orientation was conducted by the Aboriginal and Torres Strait Islander Health-Registered Training Organisation National Network in 2009 and a report detailing the results of this analysis was provided to the department in November of that year. Authors of the report414 recommended the creation of orientation packages and the availability of ongoing training for ATSIOWs, led by Aboriginal Community Controlled Health Registered Training Organisations.

413 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.414 Aboriginal and Torres Strait Islander Health Registered Training Organisation National Network 2009, An orientation, education and training needs analysis for the new and existing Aboriginal and Torres Strait Islander health workforce, Final Report, ATSIHRTONN, Adelaide.








The department then funded jurisdictional consultation workshops arranged by NACCHO in Western Australia, South Australia, New South Wales, Victoria and Queensland between March and June 2010. The workshops brought together Divisions of General Practice, state/territory health departments and the IHS sector to discuss and respond to the needs analysis report. Based on the outcomes of these workshops, NACCHO affiliates submitted proposals (ranging in value from $60,000 to $90,000) to develop and deliver orientation packages tailored to the needs and preferences identified in each jurisdiction. The proposals identify how the orientation package will be developed and delivered. Funding agreements were executed by 30 June 2010 with all jurisdictions where a workshop was held. On 31 December 2009, the department also entered a funding agreement with GPET for additional GP registrar placements. On 1 January 2010, funding for 38 GP registrar placements was added to the Aboriginal and Torres Strait Islander Health Training Posts. Because the Workforce Support, Education and Training (C1) measure’s funding added to an existing program, GP placements began immediately. In the 2010 calendar year, 46 placements were made (eight above the 2008 baseline), creating a total of 147 placements available through the ATSIHTP altogether in 2010, indicating subscription beyond the expected levels. Placement results indicate good subscription to the placement program, but there are some constraints to sustainability and growth. Namely, at present, the GP registrar placements are only available in accredited IHSs, even though a number of mainstream primary health care practices may have predominantly Aboriginal and Torres Strait Islander clients. On 24 May 2010, the funding agreement was signed between the department and the RCNA to administer the nursing scholarships and placements. Nursing clinical placements occur in IHSs as spaces are offered and allocated. No nursing placements were made in 2009-10.In addition to the above, the Workforce Training and Capacity Advisory Group met six times in 2009-10. As noted above, this group was convened to provide expert advice on implementing the health workforce and training component of the ICDP.The expenditure on this measure in 2009-10 was $4.62 million. Table 22 below provides the expenditure for 2009-10 for the three main components of the Workforce Support, Education and Training (C1) measure.Table 22: Expenditure, Workforce Support, Education and Training (C1) measure 2009-10.415 *Note: budget and expenditure as per calendar year.

Workforce Support, Education and Training (C1) measure component

Actual expenditure

ATSIOW orientation and training $0.578mGP registrar training posts* $1.976m






Workforce Support, Education and Training (C1) measure component

Actual expenditure

Nursing scholarships/placements $2.033mTotal $4.587m

The Commonwealth Implementation Plan on Closing the Gap in Indigenous Health Outcomes416 identifies four performance indicators for this measure. Table 23 below identifies performance against these indicators in 2009-10. Note that “number of ATSIOWs oriented” does not appear in the Commonwealth Implementation Plan, but has been added here to capture orientation as a mandatory activity (while training is optional). Table 23: 2009-10 performance for Workforce Support, Education and Training (C1) measure activities on Commonwealth Implementation Plan indicators.417

Performance indicator Actual performance, 2009-10Number of ATSIOWs trainedNumber of ATSIOWs oriented*

00

Number of nursing scholarships provided

0

Number of nursing clinical placements 0Number of GP registrar placements (2010 calendar year)

46 (42 FTE)

*Note: this indicator does not appear in the Commonwealth Implementation Plan.

416 Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed September 2012.417 Based on information provided by the Department of Health and Ageing.








16. Expanding the Outreach and Service Capacity of Indigenous Health Organisations

Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure at a glanceICDP priority area: Fixing the gaps and improving the patient journey.The issue being addressed: Many Indigenous health services (IHSs) experience limitations in their capacity to provide high quality primary health care services for chronic disease management. Barriers include challenges in recruiting and retaining workers, and ensuring accommodation for staff. This is particularly the case in rural and remote areas. The ICDP solution: This measure provides three types of workforce positions and capital infrastructure support to selected organisations in the IHSs sector: Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs), Practice Managers and additional health professional positions (identified based on need within communities).The supporting evidence: The IHS sector is an important source of culturally appropriate services for Aboriginal and Torres Strait Islander clients. Additional workforce positions and infrastructure assistance can enhance the service capacity of IHSs. The central causal pathway: This measure aims to increase the capacity of IHSs to provide primary health care services. In order to achieve this outcome, the measure relies on: ATSIOWs to facilitate Aboriginal and Torres Strait Islander people’s access to primary health care; Practice Managers to reduce the non-clinical duties of clinical health staff; and additional health professional positions to deliver care. IHS capacity is also increased through infrastructure improvements to staff housing and medical facilities. Reach: The reach of this measure is determined by the location and number of ATSIOWs, Practice Managers and additional health professional positions, and the number of Aboriginal and Torres Strait Islander patients who receive services through the participating IHSs. Timeframes: Within two to four years, Aboriginal and Torres Strait Islander patients are expected to increase their utilisation of health care services provided by IHSs, and IHSs are expected to deliver an increased amount of MBS items specific to Aboriginal and Torres Strait Islander people. After four years, IHSs should continue to demonstrate increased and sustainable capacity to meet the needs of the local Aboriginal and Torres Strait Islander population. Year one progress: Activities in the first year of this measure (2009-10) included stakeholder consultation, establishment of funding agreements, and selection of capital infrastructure projects.






16.1 Design of the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure

The Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure is composed of two core components: workforce expansion and program support. Workforce expansion targets three categories of positions located in IHSs: Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs); Practice Managers; and additional health professional positions. Program supports are applied at three levels: capital infrastructure projects within selected IHSs; state/territorial leadership; and national council meetings.The measure has a budget of $54.604 million over four years 2009-10 to 2012-13.

Workforce development

A target of 86 Full Time Equivalent (FTE) ATSIOWs are being recruited in IHSs across Australia. These are entry-level, non-clinical positions which are not expected to have previous experience delivering services in the health care sector. The role of the ATSIOWs is to promote health services and resources to Aboriginal and Torres Strait Islander community members, and to encourage patients to self-identify as Aboriginal and Torres Strait Islander when presenting at a primary health care service. ATSIOWs may perform a variety of duties depending on their personal and professional background or geographic location, including transportation of patients to health care appointments and following up on care. ATSIOWs employed under the measure are generally expected, but not required, to be of Aboriginal or Torres Strait Islander descent and, most importantly, are expected to have established relationships in their communities. ATSIOWs receive orientation, access to training, and the opportunity to attend national workshops funded through the Workforce Support, Education and Training (C1) measure. Also within the measure, 43 Practice Managers are being progressively established in priority locations nation-wide. Practice Managers are expected to coordinate non-clinical aspects of service delivery within IHSs. The department has not provided a role description for Practice Managers, so specific aspects of the Practice Manager role are being defined by each health service host organisation. Roles may commonly include administrative functions such as managing billing, reception and accreditation. In addition, 30 additional health professional positions will be established in selected IHSs in rural and remote locations; the type and location of positions is based on identified local needs. These positions may include general practitioners (GPs), registered nurses (RNs) and Aboriginal Health Workers (AHWs). No training provisions have been included in this measure (or other ICDP measures) for Practice Manager or the other health professional roles funded, as






these positions are not expected to be filled by new entrants to the workforce.Workforce positions under the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure have been allocated to jurisdictions based on the proportion of the total Aboriginal and Torres Strait Islander population. Indigenous Health Partnership Forums (IHPFs) in each jurisdiction are engaged in determining the placement of workforce positions. The IHSs involved in the measure provide a range of reports to the department through the regular reporting channels for OATSIH-funded organisations. These include: quarterly updates on the number of positions recruited; quarterly verbal and/or written reports and updates to the relevant

state/territory department office; audited financial reports at the end of financial year; and annual reports.

Project supports

As noted above there are a number of distinct project supports that are provided through this measure: capital infrastructure projects within selected IHSs; state/territorial leadership; and national council meetings.$12 million is available over the first four years of the ICDP to provide grants to a small number of IHSs to complete infrastructure projects such as clinic upgrades or staff housing. Capital infrastructure projects are located across a small number of regional, remote or very remote sites.The measure is also providing funding towards meeting expenses for three meetings of the National Aboriginal and Torres Strait Islander Health Equality Council (NATSIHEC).418 NATSIHEC is a primary advisory body to the Minister for Indigenous Health and provides advice on the implementation of the ICDP overall.

Stakeholders

The stakeholders of this measure include internal and external parties at local/community, regional, jurisdictional and national levels. Table 24 below provides an overview of the key stakeholder groups and their roles in relation to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure.

418 Previously the National Indigenous Health Equity Council. 198





Table 24: Key stakeholders and roles in relation to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure.419

Stakeholder Role in Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure

Department Central Office Manage the design and implementation of the measure

Department state / territory offices

Manage relationships and funding agreements with IHSs in each jurisdictionManage relationships with IHPFs in each jurisdiction

IHPFs In each jurisdiction, provide advice on the location of workforce positions


Host the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) workforceReport on activities and progress for the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure through regular OATSIH reporting mechanisms

ATSIOWs Provide services to Aboriginal and Torres Strait Islander community members and hosting IHSs

Practice Managers Provide services to Aboriginal and Torres Strait Islander community members and hosting IHSs

Other health professional positions

Provide services to Aboriginal and Torres Strait Islander community members and hosting IHSs

Aboriginal and Torres Strait Islander people

Receive services from IHSs participating in the Improving Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure, including directly from ATSIOWs and other workforce positions


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).420 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure. 419 Based on information provided by the Department of Health and Ageing. 420 Council of Australian Governments 2011, National Indigenous Reform Agreement (Closing the Gap), Schedule D, viewed September 2012.








Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. This measure improves access to primary health care services which is

considered to be a main avenue to improve the health outcomes of Aboriginal and Torres Strait Islander people.

Placement of workforce positions has occurred through priority setting including needs analysis by the IHPFs in each jurisdiction.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. Consultation has occurred with IHPFs to identify priority locations for

placement of workforce positions. ATSIOW positions are expected to be recruited from the local community, and

play a key role in engaging with community members to improve access to primary health care.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The measure is funded over the first four years – 2009-10 to 2012-13.

Workforce expansion and capital infrastructure projects provide benefits that extend beyond the initial funding period. Sustainability of the measure will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. The aim of the measure is to improve Aboriginal and Torres Strait Islander

access to primary health care services through strengthening the capacity of IHSs and expanding the workforce.

The ATSIOW workforce promotes community engagement and culturally appropriate care delivery.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. Collaboration between government at different levels and other key

stakeholders occurs through the IHPF, which identifies priority locations for placement of workforce positions.

ATSIOWs from this and the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measures have jointly participated in national workshops, offering the opportunity for collaboration across the IHS and mainstream primary health care sectors.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. This measure is subject to regular performance monitoring to OATSIH, and is

reported publicly on an annual basis.






Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure is included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

16.2 Rationale and supporting evidenceThe measure aims to increase the capacity of IHSs through workforce positions, with the expectation of enhancing service delivery and increasing access to health care for Aboriginal and Torres Strait Islander people, including chronic disease prevention, detection and treatment. Aboriginal and Torres Strait Islander people have lower rates of access to primary health care than other Australians421, which is related to a range of factors including geographical accessibility, perceived cultural inappropriateness, and transport issues.422,423 Research suggests that provision of health services in culturally appropriate ways and settings can significantly improve Aboriginal and Torres Strait Islander people’s access to services.424 Based on this rationale, IHSs have a core role in improving access to primary health care in Aboriginal and Torres Strait Islander communities. Even IHSs can encounter challenges to improving patient access and service delivery such as population diversity, identification of Aboriginal and Torres Strait Islander people, high levels of patient mobility, and patients residing in locations that are geographically distant from the IHS itself.425 Additionally, there are difficulties relating to recruitment and retention of workers in the IHS sector, reflecting in high vacancy rates for health professional positions.426 Availability of accommodation for staff is a particular issue in remote areas.

421 Deeble J, Shelton Agar J & Goss J 2008, ‘Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004–2005’, Health and welfare expenditure series, no. 33, AIHW, Canberra. 422 Gruen RL, Weeramanthri TS & Bailie RS 2002, ‘Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability’, Journal of Epidemiological Community Health, vol. 56, pp 517-512. 423 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.424 Aboriginal Health and Medical Research Council Consulting Service & Mandala Consulting2004, Increasing access to Services in New South Wales for Aboriginal People at Risk of Contracting of Who Have Blood Borne Infections, NSP Annual Report 2004, New South Wales.425 Couzos S & Thiele DD 2010, ’The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, pp. 154-157.426 Australian Institute of Health and Welfare 2010, Aboriginal and Torres Strait Islander health services report, 2008-09, OATSIH Services Reporting – key results, cat. no. IHW 31, AIHW, Canberra.









Evidence related to workforce development

The Commonwealth Implementation Plan for Closing the Gap in Indigenous Health Outcomes427 cites evidence broadly in support of ATSIOW positions. The Plan states that “using IOWs [Indigenous Outreach Workers] to increase access to health care is a model that has demonstrated success in Australia when well supported by the health system.” There is also research evidence to suggest that it is essential that ATSIOWs have a strong cultural understanding and local knowledge. Aboriginal and Torres Strait Islander people are more likely to access primary health care that is provided by another person from the same culture.428,429 Culturally competent health workers who are not Aboriginal or Torres Strait Islander may also be acceptable to Aboriginal and Torres Strait Islander patients.430 One of the roles of ATSIOWs is to encourage self-identification of Aboriginal and Torres Strait Islander people to health care providers in the primary health care setting. Early identification is considered to be an essential component of programs aiming to address chronic disease.431

The Practice Manager position is intended to enhance the non-clinical capacity of IHSs. Evidence confirms that managers in the health care setting can ensure that the roles of other staff are clearly defined and that staff are supported.432,433

Improved management practices can result in increases in regular testing and monitoring by AHWs, RNs and GPs, improved prescribing practices by GPs, and consequently, increases in the likelihood of good intermediate outcomes for patients.434 Team-based care is considered an essential component of a functional primary health care practice, and something which Practice Managers can have a role in facilitating and encouraging.435

427 Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed September 2012.428 Based on information provided by the Department of Health and Ageing. 429 Hayman NE, White NE & Spurling GK. 2009, ‘Improving Indigenous Patients’ access to mainstream health services: the Inala experience’, Medical Journal of Australia, vol. 190, no. 10, pp. 604-606. 430 Aboriginal Health and Medical Research Council Consulting Service & Mandala Consulting2004, Increasing access to Services in New South Wales for Aboriginal People at Risk of Contracting of Who Have Blood Borne Infections, NSP Annual Report 2004, New South Wales.431 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.432 Si D, Bailie RS, Togni SJ, D'Abbs PHN & Robinson GW 2006, ‘Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis’, Medical Journal of Australia, vol. 185, no. 1, pp.40-45.433 Shepherd F, Battye K & Chalmers E. 2003. Improving access to cardiac rehabilitation for remote Indigenous clients, Australian and New Zealand Journal of Public Health, vol. 27, no. 6, pp. 632-626434 Si D, Bailie RS, Togni SJ, D'Abbs PHN & Robinson GW. 2006. Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis, Medical Journal of Australia, vol. 185, no. 1, pp. 40-45.








There is a demand for needs-based recruitment of health and medical professionals such as nurses, doctors and allied health workers who have skills and capabilities in Aboriginal and Torres Strait Islander health, as the health care needs of this population, though, can vary significantly within communities and across locations.436 Broadly the focus of this measure on recruiting culturally competent health professionals is supported by research, which shows the availability of culturally competent health professionals can support access to primary health care by Aboriginal and Torres Strait Islander people. 437


Lack of accommodation for health workforce, particularly in rural and remote locations, is frequently identified as a recruitment issue by governments438 and in the literature.439 Many remote health services struggle to raise funds for needed infrastructure and clinical equipment upgrades.440 The grants available through the measure support selected IHSs to address some of these issues. 16.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving improved Aboriginal and Torres Strait Islander access to primary health care as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

435 Shepherd F, Battye K & Chalmers E 2003, ‘Improving access to cardiac rehabilitation for remote Indigenous clients’, Australian and New Zealand Journal of Public Health, vol. 27, no. 6, pp. 632-626.436 Couzos S & Thiele DD 2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, pp. 154-157.437 Aboriginal Health and Medical Research Council Consulting Service & Mandala Consulting2004, Increasing access to Services in New South Wales for Aboriginal People at Risk of Contracting of Who Have Blood Borne Infections, NSP Annual Report 2004, New South Wales.438 Office of the Coordinator General for Remote Indigenous Services 2011, Six Monthly Report, Northern Territory Priority Communities, Australian Government, Canberra. 439 Smith K, Flicker L, Shadforth G, Carroll E, Ralph N, Atkinson D, Lindeman M, Schaper F, Lautenschlager Northern Territory & LoGiudice D 2011, ‘Gotta be sit down and worked out together: views of Aboriginal caregivers and service providers on ways to improve dementia care for Aboriginal Australians’, Rural and Remote Health, vol. 11.440 Australian Indigenous HealthInfoNet 2008, Review of the impact of housing and health - related infrastructure on Indigenous health, viewed October 2011.




http://www.healthinfonet.ecu.edu.au/determinants/physical-environment/reviews/our-review

http://www.healthinfonet.ecu.edu.au/determinants/physical-environment/reviews/our-review



Expanding the Outreach and Service Capacity of

Indigenous Health Organisations

Increase in IHS capacity to provide outreach support to Aboriginal and Torres Strait Islander patients

Aboriginal and Torres Strait Islander people increase

their utilisation of primary health care services

Increase in IHS capacity to deliver primary health care

services

Increase in IHS capacity to manage non-clinical

functions

Improvements in IHS infrastructure to

accommodate staff and deliver services

Practice Managers are effective in reducing non-clinical duties of clinical health staff

ATSIOWs are effective in facilitating Aboriginal

and Torres Strait Islander people’s access to primary health care

services

Recruitment and retention of ATSIOWs, Practice Managers and

additional health professional positions

Figure 21: Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure causal model. Source: KPMG. 16.4 Reach and timeframesThe potential reach441 of this measure is determined by the location and number of ATSIOWs, Practice Manager and additional health professional positions, and the number of Aboriginal and Torres Strait Islander patients who receive services through the participating IHSs. As at 2009-10 it is intended that 86 FTE ATSIOWs, 43 Practice Managers and 30 additional health workforce positions are recruited over the life of the measure.In the short term (two to four years), the implementation of the measure workforce and program supports is expected to result in an increased capacity of IHSs to provide outreach and health services. As a result, and through the promotional work of the ATSIOWs, it is expected that the Aboriginal and Torres Strait Islander population will increase their use of primary health care services. As a medium term result (four years and greater), the measure is expected to result in an increased and sustained service delivery capacity within IHSs. Specifically, the measure may contribute to the following changes: an increase in the number of ATSIOWs, Practice Managers and additional

health professionals employed in IHSs; and an increase in the number of Aboriginal and Torres Strait Islander people who

access these services.







As a result of increased service utilisation, it is anticipated that Aboriginal and Torres Strait Islander patients will have a sustained reduction in the incidence and prevalence of clinical risk factors associated with chronic disease. 16.5 Complementary activityThis Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure is closely related to the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure; as both involve recruitment of an ATSIOW workforce to enhance Aboriginal and Torres Strait Islander people’s access to services (the former in IHSs and the latter in mainstream primary health care services). Mainstream and IHS based ATSIOWs jointly receive orientation, access to training, and networking through national workshops through the Workforce Support, Education and Training (C1) measure.There is potential that IHSs hosting the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) workforce may also host other workforce positions funded under the ICDP such as the combined Regional Tackling Smoking Healthy Living Teams (RTSHLTs) under the National Action to Reduce Indigenous Smoking Rates (A1) and Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2) measures, and Care Coordinators funded under the Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3b) measure. This may facilitate joint service delivery and program activity; increasing the range of health services available from relevant from relevant fund holders. The measure also has links to the PBS Co-payment measure (B1), the PIP Indigenous Health Incentive (B3a) measure, and both the urban and rural/remote aspects of the Increasing Access to Specialist and Multidisciplinary Team Care (B5a and b) measures as ATSIOWs may facilitate access to the supports for patients provided under these measures. Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. Significant complementary activity is also being undertaken through National Aboriginal and Torres Strait Islander workforce programs, strategies and initiatives. Although the focus of workforce strategies is on existing positions rather than new positions, such as ATSIOWs, the central aims around increasing the capacity of the workforce are consistent. Appendix B provides Policy Maps which identifies these complementary activities. 16.6 Expanding the Outreach and Service Capacity of Indigenous

Health Organisations data sourcesEvaluation of this measure will be informed by a range of primary data sources such as consultation with ATSIOWs, Practice Managers and other funded workers, consultations with IHSs, community members and other stakeholders, review of program documentation and the organisational and health workforce surveys.






In terms of secondary data sources, OATSIH Services Reporting data and MBS data will also be analysed. Further discussion of these data sources, uses and limitations is provided in Appendix E. The Evaluation Framework442 identifies two indicators to measure the whole of Package which are directly relevant to this measure. These are: Self-reported access to health services, as reported in section 3.12 of the HPF.


Size of the workforce within IHSs, as reported in section 3.20 of the HPF. In 2009-10, the number of full time equivalent (FTE) staff within Aboriginal and Torres Strait Islander primary health care services funded by the Australian Government was 4,835 which is composed of 2,745 Aboriginal and Torres Strait Islander staff, and 2,090 non-Indigenous staff.

Refer to Appendix F for further information about these indicators, including original sources. The evaluation will monitor and provide updates on these indicators as they become available.16.7 Year one progress In 2009-10, consultations occurred with the IHPFs in each jurisdiction to determine the priority locations for ATSIOWs and Practice Managers, and locations for the additional health professional positions in rural and remote areas. To guide the prioritisation process, the department provided the IHPFs with selection criteria for high priority locations, including: size of the Aboriginal and Torres Strait Islander population; high capacity organisations (considered appropriate to receive early implementation funding); and consideration of other similar positions already in place. The department considered the advice of the IHPFs in the final selection of locations for the additional workforce. Consultations with NACCHO also led to a change of title for the ATSIOW position during 2009-10, which were previously called Indigenous Outreach Workers. Table 25 below identifies 2009-10 performance indicators identified in the Commonwealth Implementation Plan for Closing the Gap in Indigenous Health Outcomes443 relevant to this measure - the number of funded positions and actual recruitment for 2009-10 for the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) workforce.

442 Urbis Pty Ltd 2010, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volume 1, Department of Health and Ageing, Canberra.443 Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed September 2012.










Table 25: 2009-10 funded and actual recruitment for Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2).444

Positions 2009-10 Funded 2009-10 Actual recruitment

ATSIOW positions recruited 40 8Practice manager positions recruited 9 0Additional health professionals recruited

6 0

Total 55 8

The OATSIH Services Reporting (OSR) data provides some insight into staff profiles and service delivery in IHSs (see Appendix E for further discussion of the OSR). In 2009-10, the organisations responding to the OSR questionnaire reported increases across various measures; however, this may be due in part to the increased number of organisations which responded in 2009-10. Table 26 below presents staff and service data from the 2008-09 and 2009-10 OSRs.Table 26: OSR selected primary health care service statistics by service type for 2008-09 and 2009-10.445

Summary statistic 2008-09 2009-10Number of responses 205 223Clients 375,000 456,000Number of Aboriginal and Torres Strait Islander clients446

294,126 356,897

Episodes of health care 2,100,000 2,400,000FTE Staff 4,300 4,841FTE Aboriginal and Torres Strait Islander Health Workers

745 867

FTE Managerial, administrative, support and other roles

1,400 1,727

The OSR data will continue to be considered throughout the evaluation to contribute to discussion about the potential impact of the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure on IHS staff numbers and service delivery.

444 Based on information provided by the Department of Health and Ageing. 445 Australian Institute of Health and Welfare 2011, Aboriginal and Torres Strait Islander health services report 2009–10: OATSIH Services Reporting—key results, cat. no. IHW 56, AIHW, Canberra.446 Many IHSs do provide services to non-Aboriginal and Torres Strait Islander patients, however priority is usually given to meeting the needs of Aboriginal and Torres Strait Islander community members.






In 2009-10, three capital infrastructure projects were selected for funding, including a clinic extension for an IHS in Victoria, a new clinic and staff housing facilities in Western Australia, and a new clinic space in New South Wales. Three NIHEC meetings were conducted in 2009-10. These meetings covered all aspects of the ICDP, not just this measure. Table 27 below shows actual expenditure for the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure for the 2009-10 year, separated into three components.Table 27: 2009-10 actual expenditure for Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure.447

Component 2009-10 actual expenditure

Workforce $2,989,000Capital infrastructure projects $4,190,000

NATSIHEC meetings $151,728Total $7,330,728






17. Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care

Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure at a glanceICDP priority area: Fixing the gaps and improving the patient journey.The issue being addressed: Aboriginal and Torres Strait Islander people have lower rates of access to primary health care than other Australians, particularly mainstream primary health care services, due to cultural barriers. The ICDP solution: This measure provides a workforce of Indigenous Health Project Officers (IHPOs) and Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs) to enhance access to culturally sensitive mainstream primary care for Aboriginal and Torres Strait Islander people. The supporting evidence: Aboriginal and Torres Strait Islander people are more likely to access mainstream primary health care which is culturally sensitive, and facilitated through a worker of their own cultural background (e.g., ATSIOWs). The central causal pathway: This measure aims to result in increased capacity to provide accessible mainstream primary health care services to Aboriginal and Torres Strait Islander people, as demonstrated through, for example, the delivery of MBS items specific to Aboriginal and Torres Strait Islander people. In order to achieve this outcome, the measure relies on reducing barriers to culturally sensitive mainstream primary care through outreach services and improving providers’ understanding of appropriate care. Reach: The reach of this measure is determined by the number and location of Divisions of General Practice who receive workforce positions through this measure, and the number of Aboriginal and Torres Strait Islander patients who receive services through these practices.Timeframes: Within two to four years, Aboriginal and Torres Strait Islander patients are expected to increase their utilisation of mainstream primary health care services, and such services are expected to deliver an increased amount of MBS items specific to Aboriginal and Torres Strait Islander people. After four years, the mainstream primary health care practices should continue to demonstrate an increased and sustainable capacity to deliver culturally sensitive services to Aboriginal and Torres Strait Islander people.Year one progress: In the first year of the measure’s implementation, 2009-10, activities included consultation, establishment of funding agreements, and recruitment and orientation of workforce positions.






17.1 Design of the Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure (also referred to as the Improving Access to Mainstream Primary Care measure)

This measure includes the establishment of two types of workforce positions within Divisions of General Practice (Divisions), as well as program supports that operate at the local, state and national levels to bolster the success of the measure. The measure has a budget of $71.76 million over four years 2009-10 to 2012-13.The measure seeks to improve the cultural competency of mainstream primary health care providers, and their engagement of Aboriginal and Torres Strait Islander patients, to enhance access to mainstream services.

Workforce development

Workforce development includes the establishment of two types of workers in selected Divisions of General Practice. This includes ATSIOWs and Indigenous Health Project Officers (IHPOs). IHPOs are also being established in coordination roles in the AGPN, NACCHO and NACCHO affiliates. Over 80 FTE ATSIOW positions will be established in selected Divisions of General Practice over the first two years of the ICDP. Funding for ATSIOW positions is generally proportional to the Aboriginal and Torres Strait Islander population in each jurisdiction, and take account of the number of PIP registered health care practices448 in the Division. Only those Divisions receiving funding for an IHPO will receive funding for an ATSIOW position, as ATSIOWs are expected to receive on-the-job support from IHPOs. IHPFs in each jurisdiction were consulted about the allocation of positions. The main role of ATSIOWs is to promote mainstream primary health care services among the Aboriginal and Torres Strait Islander population. While Divisions have the flexibility to tailor the role and activities of the ATSIOWs to suit local needs, the general duties of this non-clinical role are expected to be: community liaison with Aboriginal and Torres Strait Islander communities to

encourage increased use of health services; administration and support for the IHPO; providing practical assistance to Aboriginal and Torres Strait Islander

community members to access health services; and providing feedback to the Division of General Practice regarding access

problems that may be restricting Aboriginal and Torres Strait Islander people access to health services.449

448 See section for more information on the PIP Indigenous Health Incentive.449 Department of Health and Ageing 2010, Closing the Gap, Improving Indigenous Access to Mainstream Primary Care, Indigenous Health Project Officers and Aboriginal and Torres Strait Islander Outreach Workers, Program Guidelines. Version 1.2, viewed September 2012.




http://www.health.gov.au/internet/ctg/publishing.nsf/Content/prog-guidelines-ihpo-toc





ATSIOWs are entry-level positions, and require strong links to the local community and effective communication skills. ATSIOW positions are intended to be filled by local Aboriginal and Torres Strait Islander people. IHPOs are the other element of the Improving Access to Mainstream Primary Care (C3) measure workforce. At least 80 FTE IHPOs will be recruited in Divisions of General Practice or in coordinator positions at the state or national levels. As for the ATSIOWs, funding for these positions is based on the size of the Aboriginal and Torres Strait Islander population in each jurisdiction, with IHPFs consulted on the allocation of positions in each state or territory. The allocation of funding for the IHPO workforce within jurisdictions is based on the size of the Aboriginal and Torres Strait Islander population in the Division, with proportionately more funding allocated to Divisions with larger populations. Not all Divisions received funding for an IHPO position.Like ATSIOWs, the IHPOs also have a non-clinical role. These workers employ strategies to improve access to mainstream primary health care, encourage Aboriginal and Torres Strait Islander patient self-identification to mainstream health care practices, and promote collaboration between Divisions and local IHSs. The role of the IHPO is broader than this measure alone, as these workers are expected450 to promote relevant ICDP measures to primary care providers, and to provide activities and approaches that address access barriers and promote culturally sensitive service delivery. The IHPO function is open for tailoring by the host organisation, as “there is no prescriptive role statement for Indigenous Health Project Officer positions.”451 The qualifications for the IHPO position are “experience in working with Indigenous Australians [as] required for the performance of the activities outlined in…Program Guidelines.”452 While not a requirement, the Program Guidelines provide encouragement to Divisions to employ Aboriginal and Torres Strait Islander people as IHPOs where possible.

Program supports

The Improving Access to Mainstream Primary Care (C3) measure includes the establishment of IHPO positions for national and state/territory leadership and coordination. This includes one position within the AGPN (national coordinator) and one position in each SBO of the Divisions of General Practice. While not

450 Department of Health and Ageing 2010, Performance Indicators for IHPOs in Divisions of General Practice. Closing the Gap, Improving Indigenous Access to Mainstream Primary Care, Indigenous Health Project Officers and Aboriginal and Torres Strait Islander Outreach Workers, Program Guidelines. Version 1.2 , viewed September 2012.451 Department of Health and Ageing 2010, Performance Indicators for IHPOs in Divisions of General Practice. Closing the Gap, Improving Indigenous Access to Mainstream Primary Care, Indigenous Health Project Officers and Aboriginal and Torres Strait Islander Outreach Workers, Program Guidelines. Version 1.2 , viewed September 2012, p. 9.452 Department of Health and Ageing 2010, Performance Indicators for IHPOs in Divisions of General Practice. Closing the Gap, Improving Indigenous Access to Mainstream Primary Care, Indigenous Health Project Officers and Aboriginal and Torres Strait Islander Outreach Workers, Program Guidelines. Version 1.2 , viewed September 2012.




http://www.health.gov.au/internet/ctg/publishing.nsf/Content/prog-guidelines-ihpo-toc~attachment13











originally a part of the measure’s design, funding has also been provided for IHPO coordinators in NACCHO and each jurisdictional NACCHO affiliate. The state based coordinators liaise with stakeholders to raise awareness of the ICDP measures and to coordinate shared activities and resources. Participating Divisions of General Practice and SBOs are also required to complete a needs assessment. While the process for completing the needs assessment is at the discretion of the SBO, the Report is expected to cover population characteristics, existing services and programs, stakeholder views and options and priorities for ongoing work.453 The Improving Access to Mainstream Primary Care measure also includes a mentoring support program for IHPOs. The purpose of the program is to share project experiences, capture knowledge, access national support networks and reduce the duplication of effort. This work is being overseen by a reference group involving AGPN and a number of SBO IHPOs. The program includes sharing relevant resources on the AGPN website library; an online webinar on peer mentoring; and an IHPO newsletter.

Stakeholders

Stakeholders for the Improving Access to Mainstream Primary Care include internal and external parties from the local / community, regional, jurisdictional and national level.Table 28 below provides an overview of key stakeholder groups and their roles in relation to this measure.

453 Department of Health and Ageing 2010, Closing the Gap, Improving Indigenous Access to Mainstream Primary Care, Indigenous Health Project Officers and Aboriginal and Torres Strait Islander Outreach Workers, Program Guidelines. Version 1.2, viewed September 2012.









Table 28: Key stakeholders and roles in relation to the Improving Access to Mainstream Primary Care (C3) measure.454

Stakeholder Role in Improving Access to Mainstream Primary Care (C3) measure


Develop program designProvide oversight to Department State / Territory Offices (STOs)Coordinate national-level monitoring and reportingManage funding agreement with AGPN

Department State / Territory Offices

Manage funding agreements with Divisions, SBOs and NACCHO affiliates

Indigenous Health Partnership Forums

Indigenous Health Partnership Forums (IHPFs) in each jurisdiction were consulted about the allocation of positions.

Australian General Practice Network

Host the national coordinator IHPOsProvide national coordination and leadership to the Divisions of General Practice Network in the area of Aboriginal and Torres Strait Islander health, and provide national support and coordination for the state based coordinators in NACCHO Affiliates

NACCHO Host the national coordinator IHPOsProvide national coordination and leadership to the Divisions of General Practice Network in the area of Aboriginal and Torres Strait Islander health, and provide national support and coordination for the state based coordinators in NACCHO Affiliates

State Based Organisations of the National Divisions of General Practice

Host the state coordinator IHPO positionsProvide state level leadership including increasing awareness of ICDP measures and working to establish and maintain an effective network of IHPOs.

NACCHO affiliates Host the state coordinator IHPO positionsProvide state level leadership including increasing awareness of ICDP measures and working to establish and maintain an effective network of IHPOs.


Host ATSIOW and IHPO workforce positionsReport to the department as per funding agreement






Stakeholder Role in Improving Access to Mainstream Primary Care (C3) measure

IHPOs Provide a focus on Aboriginal and Torres Strait Islander health issues in mainstream primary care providersPromote collaboration between mainstream primary health care practices and the IHSs sectorPromote the ICDP broadly

ATSIOWs Provide practical assistance to Aboriginal and Torres Strait Islander community members to access available health care services


Receive practical assistance and services from ATSIOWs


Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).455 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Improving Access to Mainstream Primary Care (C3) measure. Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. This measure improves access to primary health care services which is

considered to be a main avenue to improve the health outcomes of Aboriginal and Torres Strait Islander people.

Placement of workforce positions has occurred through priority setting including needs analysis by the IHPFs in each jurisdiction.

Funding for positions in the Divisions of General Practice is based on the size of the Aboriginal and Torres Strait Islander population.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. Divisions of General Practice are required to work with local IHSs for shared

planning and priority setting.Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The measure is funded over the first four years – 2009-10 to 2012-13.

Workforce expansion and capital infrastructure projects provide benefits that extend beyond the initial funding period. Sustainability of the measure will be further assessed in later evaluation reports.









Expected changes to the cultural accessibility of mainstream primary health care practices and relationships with the IHS sector may be sustained beyond the guaranteed funding period. The sustainability of this measure will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. A central role for ATSIOWs and IHPOs is to improve the cultural accessibility of

mainstream primary health care services for Aboriginal and Torres Strait Islander Australians.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. There is ongoing collaboration within the department and with AGPN, SBOs

and NACCHO as the primary stakeholders. Collaboration in the first year of implementation has included meetings, workshops and correspondence between the organisations.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. Fund holders for this measure provide regular formal reporting as required in

the funding agreement. The department monitors the performance of Divisions on a six monthly basis against program performance indicators. Reporting occurs through six and twelve month reports, an annual plan and annual budget.

The Improving Access to Mainstream Primary Care (C3) measure is included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

17.2 Rationale and supporting evidenceThe Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3) measure is designed to enhance the capacity of mainstream primary health care providers to provide culturally appropriate care, so as to improve the access of Aboriginal and Torres Strait Islander people to mainstream primary health care. Aboriginal and Torres Strait Islander people have lower rates of access to primary health care than other Australians, particularly when it comes to accessing mainstream primary health care services.456,457 Cultural barriers such as perceived cultural inappropriateness and lack of access to interpreters can significantly impact on Aboriginal and Torres Strait Islander peoples’ willingness

456 Hayman NE, White NE & Spurling GK 2009, ‘Improving Indigenous patients’ access to mainstream health services: the Inala experience’, Medical Journal of Australia, vol. 190, no. 10, pp. 604-606.457 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, no. 4, pp. 196-201.






to seek out health care from mainstream providers.458 Self-identification by Aboriginal and Torres Strait Islander people to health care providers may be problematic, as can identification by mainstream providers459,460 and, as a result, Aboriginal and Torres Strait Islander patients may not receive tailored, appropriate and/or needs-based care. This measure aims to respond to these issues through the ATSIOW and IHPO workforce positions, including national and state coordinator roles and other program supports.

Evidence related to workforce positions

There is evidence to suggest that it is essential that ATSIOWs have a strong cultural understanding. Aboriginal and Torres Strait Islander people are more likely to access primary health care that is provided by another person from the same culture.461,462 Culturally competent non-Aboriginal and Torres Strait Islander health workers may also be acceptable to Aboriginal and Torres Strait Islander patients.463

Cultural awareness training is recognised as one way to increase the cultural competency of mainstream primary health care providers. Another important approach is increased engagement and interaction between workers concerning cultural appropriateness464, as there is expected to be between mainstream primary health care services and IHSs sectors through the work of IHPOs. ATSIOWs may also have an important role in encouraging self-identification of Aboriginal and Torres Strait Islander people to health care providers in the primary health care setting. Early identification of Aboriginal and Torres Strait Islander status is considered to be one of the fundamental elements of chronic disease prevention/management program success.465

458 Northern Territory Government Department of Health and Families 2009, Revision of the Preventable Chronic Disease Strategy Background Paper: Preventable Chronic Disease in Aboriginal Populations , viewed September 2011.459 Couzos S & Thiele DD2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, pp. 154-157.460 Couzos S & Thiele DD2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, pp. 154-157.461 Department of Health and Ageing 2011, Data request for national ICDP monitoring and evaluation project [C4 response]. 462 Hayman NE, White NE & Spurling GK 2009, ‘Improving Indigenous patients’ access to mainstream health services: the Inala experience’, Medical Journal of Australia, vol. 190, no. 10, pp. 604-606.463 Aboriginal Health and Medical Research Council Consulting Service & Mandala Consulting2004, Increasing access to Services in New South Wales for Aboriginal People at Risk of Contracting of Who Have Blood Borne Infections, NSP Annual Report 2004, New South Wales.464 Andrews B, Simmons P, Long I & Wilson R 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, no. 4, pp. 196-201.465 New South Wales Health 2010, Chronic Care for Aboriginal People Model of Care, New South Wales Department of Health, Sydney.










Recruitment of state- and national-level IHPOs is a core component of the Improving Access to Mainstream Primary Care (C3) measure. IHPOs focus on raising awareness about the measure, and other elements of the ICDP including through sharing activities and resources with primary health care providers. Improved coordination and management practices can enhance the role and contribution of health workers (such as Aboriginal Health Workers466), and facilitate sharing of activities, knowledge and resources. Coordination supports delivery of more effective programs.467,468 The Improving Access to Mainstream Primary Care (C3) measure supports also include community-level needs assessments, aiming to ensure that implementation of the measure is tailored and thus relevant to local contexts. It is widely recognised that the needs of Aboriginal and Torres Strait Islander people vary significantly across locations469 and that a strong understanding of local needs is required to deliver effective programs.470 Specifically, approaches that are evidence-based yet reflective of local community contexts, and approaches which harmonise with local ways of life, are considered more likely to be effective. 471 A program implementation strategy that is sufficiently flexible to take account of local conditions supports program effectiveness and sustainability.472 Involving the local community in adapting what is known to work elsewhere to local conditions and priorities has been found to be essential to support success. 473 17.3 Central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the

466 Si D, Bailie RS, Togni SJ, D'Abbs PHN & Robinson GW 2006, ‘Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis’, Medical Journal of Australia, vol. 185, no. 1, pp.40-45.467 Queensland Health 2011, Information sharing between mental health workers, consumers, carers, family and significant others, Queensland Government, Brisbane. 468 Department of Health and Ageing 2008, Towards a National Primary Health Care Strategy: A Discussion Paper from the Australian Government, Department of Health and Ageing, Canberra. 469 Couzos S & Thiele DD 2010, ‘The new “Indigenous health” incentive payment: issues and challenges’, Medical Journal of Australia, vol. 192, no. 3, pp. 154-157.470 Jeremy R, Tonkin A, White H, Riddell T, Brieger D, Walsh W, Zeitz C, Brown A & Kritharides L 2010, ‘Improving cardiovascular care for Indigenous populations‘, Heart Lung and Circulation, vol. 19, no. 5-6, pp. 344-350.471 Griew R 2008, The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.472 Wakerman J, Chalmers EM, Humphreys JS, Clarence CL, Bell AI, Larson A, Lyle D & Pashen DR 2005, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183, no. 10, pp. S64-S68.473 Griew R 2008, The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians, Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing, Canberra.






measure. The expected steps that should occur in achieving improved Aboriginal and Torres Strait Islander access to mainstream primary health care as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Mainstream primary health care practices

change their practices in order to provide

culturally sensitive care delivery


engage with mainstream primary health care practices

ATSIOWs are effective in facilitating Aboriginal

and Torres Strait Islander people’s access to mainstream primary health care practices

Recruitment and retention of ATSIOWs

and IHPOs

IHPOs are effective in implementing initiatives

that address access barriers and promote

culturally sensitive care delivery

Engaging Divisions of General Practice to Improve Aboriginal and Torres Strait Islander People’s Access to Mainstream Primary Care

Increase in capacity to provide support to


Aboriginal and Torres Strait Islander people increase

their utilisation of mainstream primary health

care services

Increase in capacity of mainstream primary health

care practices to deliver culturally sensitive primary

health care services

Reduced barriers to culturally sensitive care

delivery

Figure 22: Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care causal model. Source: KPMG. 17.4 Reach and timeframesThe potential reach474 of the measure will be determined by factors including the number and location of mainstream primary health care practices who receive workforce positions through this measure, and the number of Aboriginal and Torres Strait Islander patients who receive services through these practices.As an early result (one to four years), the Improving Access to Mainstream Primary Care (C3) measure is expected to result in greater understanding of Aboriginal and Torres Strait Islander health issues and culture among mainstream primary health care providers, and subsequently, culturally sensitive care delivery. It is anticipated that Aboriginal and Torres Strait Islander people will have increased awareness and utilisation of mainstream primary health care services. The measure is expected to result in an increased uptake of Aboriginal







and Torres Strait Islander-specific MBS items such as health checks (Item no. 715). It is expected that the program supports included in the Improving Access to Mainstream Primary Care (C3) measure will result in improved collaboration among stakeholder groups, and particularly between mainstream primary health care practices and IHSs.In the medium term (four years and beyond), the measure should result in an increased and sustainable capacity of mainstream primary health care providers to provide culturally sensitive services to Aboriginal and Torres Strait Islander people, who will benefit from increased services, including for chronic disease management. This is expected to result in a sustained reduction in the incidence and prevalence of clinical risk factors associated with chronic disease for this population.17.5 Complementary activityThe measure is closely related to the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure in developing an ATSIOW workforce. While the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) measure provides positions in IHSs, this measure provides the complement in mainstream primary health care services. ATSIOWs within both of these measures jointly receive orientation and participate in national workshops under the Workforce Support, Education and Training (C1) measure. The Improving Access to Mainstream Primary Care (C3) measure is also connected to the Care Coordination and Supplementary Services Program (B3b) measure with Care Coordinators funded under the B3b measure expected to work together with IHPOs and ATSIOWs as an integrated workforce. This ICDP workforce is also expected to link Aboriginal and Torres Strait Islander patients to other ICDP measures such as the Urban Specialist Outreach Assistance Program (USOAP) (B5a) and Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease (MSOAP-ICD) (B5b) measures. ATSIOWs are expected to assist patients to attend appointments to receive services delivered through these measures. IHPOs are expected to raise awareness of all relevant ICDP measures within mainstream health care practices. More broadly the measure is linked to the entire ICDP, as IHPOs have a role in providing education about the whole Package. Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. While there are a number of complementary activities being undertaken at national and jurisdictional levels to enhance and support the workforce providing primary health care to Aboriginal and Torres Strait Islander people, Divisions of General Practice have not traditionally been an area of focus for such investment. Refer to Appendix D for more information on Policy Maps which identify these complementary activities.






17.6 Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care data sources

This measure will be informed by a number of primary and secondary data sources. Primary data sources will include consultations with IHPOs, ATSIOWs, fund holders and mainstream providers, in addition to community members and other relevant stakeholders. Organisational and workforce surveys will also inform the evaluation of this measure. Secondary sources include MBS data. Secondary data sources are discussed in more detail in Appendix E. The Evaluation Framework475 identifies one indicator to measure the whole of Package which is directly relevant to this measure. This is: Self-reported access to health services, as reported in section 3.12 of the HPF.


Refer to Appendix F for further information about this indicator, including the original sources. The evaluation will monitor and provide updates on these indicators as they become available.17.7 Year one progressActivities in year one included consultation, establishment of funding agreements, and recruitment and orientation of workforce positions by the Divisions of General Practice. In May 2009, AGPN hosted a consultation workshop with representatives from the Divisions of General Practice network and the department to inform potential implementation of service models and role statements for the ATSIOW and IHPO positions. On the basis of workshop discussion and further consultation with Network representatives, AGPN developed a set of recommendations to inform the implementation of the measure which addressed: objectives for the ATSIOW and IHPO roles, principles and formulas for

distributing funding for these workforces across the Network; a staged approach to the introduction of these positions to the Network; and processes for supporting and guiding the Network to address implementation

issues at a local level. Consultation also occurred with stakeholders (AGPN and Department of Health and Ageing STOs) to inform the development of program guidelines and funding agreements related to the workforce positions. Between November 2009 and January 2010, consultation occurred with IHPFs regarding the allocation of ATSIOW positions (under both the Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2) and Improving Access to Mainstream Primary Care (C3) measures). Funding agreements were offered in three stages within the 2009-10 year. Funding agreements commenced first for the IHPO positions in 30 October 2009,









and then in January 2010 the first 43 ATSIOW positions were offered. The majority of funding agreements for both positions were executed early in 2010. The offer of funding agreements for Tasmanian organisations could not proceed until the Tasmanian Government signed the National Partnership Agreement on Closing the Gap in Indigenous Health. Table 29 below identifies 2009-10 performance indicators identified in the Commonwealth Implementation Plan for Closing the Gap in Indigenous Health Outcomes476 relevant to this measure. Shortfalls are apparent in the recruitment of ATSIOWs, while targets were exceeded for recruitment of IHPO positions in this year. Included in IHPO recruitment were National Coordinator positions in the AGPN and State Coordinator positions in the SBOs.This may be partly due to the importance of having IHPOs in place prior to recruitment of ATSIOWs (so IHPOs can support ATSIOWs) in line with the design of the measure. Some Division have indicated that the need to recruit Aboriginal and Torres Strait islander people to the ATSIOW role makes it more challenging to find suitable candidates in some locations. Table 29: 2009-10 performance of the Improving Access to Mainstream Primary Care (C3) measure against Commonwealth Implementation Plan indicators.477

Performance Indicator Target2009-10

Actual performance, 2009-10

Number of ATSIOW positions recruited

At least 40 29

Number of IHPO positions recruited

At least 80 99

In 2009-10, Divisions of General Practice were required to submit a Progress Report outlining progress made against activities that they had proposed within their Interim Plan. Divisions were not required to report against performance indicators.In April 2010, the AGPN hosted an orientation workshop for IHPOs nation-wide. 157 Network employees participated in the workshop, the majority being the newly recruited IHPOs. AGPN produced the National AGPN Closing the Gap Indigenous Health Project Officer Orientation Manual as a resource in preparation for this event. The original design of the measure provided IHPO positions to only Divisions of General Practice. AGPN’s consultation workshop led to the recommendation that coordination and support functions be established at the state/territory and national levels to support the IHPO workforce. Subsequently, consultations with NACCHO resulted in additional IHPO coordinator positions housed in NACCHO and each of the NACCHO affiliates (with exception of the Australian Capital 476 Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed September 2012.477 Based on information provided by the Department of Health and Ageing.








Territory). As a result, the number of IHPOs funded by the measure increased from approximately 80 FTE at the design stage to 95 FTE IHPOs.The 2009-10 expenditure on the measure was $11.0 million.






18. Attracting More People to Work in Indigenous Health

Attracting More People to Work in Indigenous Health (C4) at a glanceICDP priority area: Fixing the gaps and improving the patient journey.The issue being addressed: There are currently low levels of participation of Aboriginal and Torres Strait Islander people in the health care workforce, and Indigenous health services (IHSs) face ongoing recruitment challenges in filling health care professional positions. The ICDP solution: This measure runs two promotional campaigns aiming to encourage greater participation in Aboriginal and Torres Strait Islander health careers, by Aboriginal and Torres Strait Islander school students (Health Heroes) and existing and training health professionals (Do Something Real). The supporting evidence: There is a lack of awareness of health career pathways and opportunities in the Aboriginal and Torres Strait Islander health sector which may limit workforce participation. Providing information about opportunities in Aboriginal and Torres Strait Islander health may encourage greater participation. 478 The central causal pathway: This measure aims to increase the workforce providing care to Aboriginal and Torres Strait Islander people. In order to achieve this outcome, the measure relies on improvements in knowledge and attitudes about work opportunities in this sector. Reach: The potential reach of the campaigns will be determined by their exposure to the target audience. No specific targets had been set at baseline, however it is intended the campaigns use multiple media in order to broaden their potential reach. Timeframes: In the shorter term (defined here as two to four years) it is expected that increased knowledge and attitude changes may occur, while desired outcomes such as greater Aboriginal and Torres Strait Islander representation in the health workforce, and greater capacity of the IHS workforce, are only expected to occur over a longer period, beyond the life of the measure. Year one progress: In the first year of the measure’s implementation (2009-10), key activities undertaken included commissioning the research and consultations to support the Health Heroes campaign, and commencing procurement to engage a consultant to develop the Do Something Real campaign.

478 National Indigenous Health Equality Council 2010, Health Workforce Target: Analysis and Recommendations Part 1: Indigenous Health Workforce, NIHEC, Canberra.






18.1 Design of the Attracting More People to Work in Indigenous Health (C4) measure

This measure consists of two national promotional campaigns: Health Heroes, which targets Aboriginal and Torres Strait Islander secondary students and their key influencers (e.g., family members); and, Do Something Real, which targets established and training health care professionals. The total budget for the Attracting More People to Work in Indigenous Health (C4) campaign for four years 2009-10 to 2012-13 is $6.8 million.

Health Heroes promotional campaign

The bulk of financial resources within the Attracting More People to Work in Indigenous Health (C4) measure have been applied to the Health Heroes promotional campaign, including developmental research.Commissioned by the department and conducted by an external research firm (Orima Research), the purpose of the developmental research was to generate knowledge to inform the development of a promotional campaign to encourage Aboriginal and Torres Strait Islander secondary school students to pursue a career in the health care sector. This primary research involved secondary schools in 18 urban, regional and remote locations in every jurisdiction, with the exception of the Australian Capital Territory. The research engaged with Aboriginal and Torres Strait Islander secondary students and parents, school staff, Aboriginal and Torres Strait Islander health students (e.g., vocational and tertiary education sector students), and Aboriginal and Torres Strait Islander health workers. This qualitative research used focus group and interviews to collect data on: intentions of Aboriginal and Torres Strait Islander students to work in the health sector; barriers and motivators within career selection; awareness of health career pathways; and communications preferences. This research has informed the development of messages and selection of media for the Health Heroes campaign. Development of the Health Heroes campaign also included interviews with national and state/territory stakeholders from the government and non-government sectors. The Health Heroes promotional campaign uses multiple media to deliver messaging, including the internet (with a website479, advertising on Facebook and YouTube480), National Indigenous television, and Aboriginal and Torres Strait Islander regional radio and newspapers. The media campaign is complemented by community engagement activity and resource kits. Community engagement sessions provide the opportunity for existing health professionals to deliver key messages to students in person, and are conducted in the school setting. Resource kits are provided to school counsellors in schools with significant numbers of Aboriginal and Torres Strait

479 Available at Health Heroes (website).480 Available at Department of Health and Ageing YouTube page.




http://www.youtube.com/user/DeptHealthAgeing#p/c/FB7B850A46074483

http://healthheroes.health.gov.au/



Islander students (defined as 10 or more such students). The resource kit includes posters, brochures, a DVD that replicates health professionals stories featured on the Health Heroes website, and re-order forms. Multiple copies of the resource kit are being provided depending on the size of the school’s Aboriginal and Torres Strait Islander student population.

Do Something Real promotional campaign

A separate stream of activity has included conducting consultations and developing a promotional campaign to raise awareness among both Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander health professionals (established and training) about the opportunity to work in the IHS sector. This campaign, Do Something Real, includes a website481 and posters distributed to IHSs, hospitals and universities. The premise of the campaign is that by featuring ‘real life’ stories of health professionals who work in the IHS sector, including through videos and blog postings, other (established and training) health professionals will be encouraged or inspired to consider careers in this sector. The department has chaired a Campaign Reference Group (CRG) to provide advice on the development of the campaign strategies, tools and activities within the measure. An additional role of the CRG is to “facilitate the engagement of non-governmental organisations and other stakeholders to build partnerships and capacity, and extend the reach of the program.”482 Membership of the CRG includes representatives from the department and health and education representative bodies in the ACCHO and mainstream sectors.

Stakeholders

Stakeholders for this measure include internal and external parties at the local/community, regional, jurisdictional and national levels. Table 30 below provides an overview of the key stakeholder groups and their roles in relation to the Attracting More People to Work in Indigenous Health (C4) measure.

481 Available at Do Something Real (website).482 Department of Health and Ageing n.d., Indigenous chronic disease – attracting more people to work in Indigenous health, Campaign Reference Group, Terms of reference, Department of Health and Ageing, Canberra.




http://dosomethingreal.govspace.gov.au/



Table 30: Key stakeholders and roles in relation to the Attracting More People to Work in Indigenous Health (C4) measure.483

Stakeholder Role in the Attracting More People to Work in Indigenous Health measure


Manage procurement process to engage agencies to provide research, creative and public relations services for the campaignManage contracts with engaged agencies for the development and implementation of campaign activity

Orima Research Conduct research for secondary student campaign, Health HeroesConcept test creative materials for secondary student campaign, Health HeroesUndertake benchmarking and tracking research to evaluate the effectiveness of the Health Heroes campaign

BCM Develop and produce advertising concepts and campaign materials for secondary student promotional campaign

Boxing Cleaver Develop and implement public relations activitiesCampaign Reference Group

Provide advice on the development of the campaign strategies, tools and activitiesFacilitate the engagement of non-government organisations and other stakeholders to extend the reach of the program

National stakeholder organisations

Through research and consultation, provide advice on both promotional campaigns

Aboriginal and Torres Strait Islander school students and their key influencers

Participate in research and concept testingConsume Health Heroes promotional materialsReceive community visits

Health care professionals and students

Consume Do Something Real promotional materials







Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).484 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Attracting More People to Work in Indigenous Health (C4) measure.Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The Attracting More People to Work in Indigenous Health (C4) measure

contributes to the targets of Closing the Gap by aiming to build the capacity of the Aboriginal and Torres Strait Islander health workforce. The workforce will provide services for chronic disease management for Aboriginal and Torres Strait Islander people, thus improving health outcomes.

An understanding of needs was achieved at the national and local levels through the developmental research conducted for the measure.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. Developmental research conducted for this measure included extensive

Aboriginal and Torres Strait Islander community consultation. Further local engagement will be achieved through community engagement

sessions which form part of the measure’s activities. The Campaign Reference Group includes representation from Aboriginal and

Torres Strait Islander organisations including NACCHO.Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The Attracting More People to Work in Indigenous Health (C4) measure is

funded over four years from 2009-10 to 2012-13. The campaigns aim to elicit longer term attitude change amongst target populations. The sustainability of the measure will be further assessed in later evaluation reports.

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. The accessibility of the campaign messages has been informed by

developmental research – for instance, the choice of medium and messages that are suited to Aboriginal and Torres Strait Islander audiences. Campaign materials have been tested with Aboriginal and Torres Strait Islander people at key stages of the campaign’s development.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services.









The Campaign Reference Group includes representation from key government representatives including the Department of Health and Ageing, and the Department of Employment, Education and Workplace Relations. Communications with the Department of Finance and Deregulation have been ongoing.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. The Attracting More People to Work in Indigenous Health (C4) measure is

included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation.

The department is also commissioning an evaluation specific to this measure.18.2 Rationale and supporting evidenceThe measure is aimed at increasing participation of Aboriginal and Torres Strait Islander people in the health workforce and engagement of health care professionals in the IHS sector. Aboriginal and Torres Strait Islander people have lower levels of participation in education and the workforce, than other Australians.485 In 2010, 46 per cent of the Aboriginal and Torres Strait Islander population aged 15 years and over were classified as employed.486 This compares to a national employment participation rate of 65.6 per cent in 2011.487 In addition Aboriginal and Torres Strait Islander people are less likely to complete schooling and undertake post school qualifications488, impacting upon their readiness and capacity to participate in the workforce. Aboriginal and Torres Strait Islander people are also significantly under-represented in the health workforce.489 Although the number of Aboriginal and Torres Strait Islander people employed in health jobs has grown, with an increase of 64 per cent between 1996 and 2006, only 3.8 per cent of employed Aboriginal and Torres Strait Islander people were working in the health related positions in 2006, representing just 1.2 per cent of the Aboriginal and Torres Strait Islander population.490

485 South Australian Department of Further Education, Employment, Science and Technology 2007, Aboriginal Profile Training and Employment September 2007, DFEEST, Adelaide.486 Australian Bureau of Statistics 2010, Labour Force Characteristics of Aboriginal and Torres Strait Islander Australians, Estimates from the Labour Force Survey 2010, cat. no. 6287.0, ABS, Canberra. 487 Australian Bureau of Statistics 2011, Labour Force, Australia Sep 2011, cat. no. 6202.0, ABS, Canberra488 Australian Bureau of Statistics 2011, Labour Force, Australia Sep 2011, cat. no. 6202.0, ABS, Canberra489 Australian Institute of Health and Welfare 2011,The health and welfare of Australia’s Aboriginal and Torres Strait Islander people an overview, AIHW, Canberra. 490 National Indigenous Health Equality Council 2010, Health Workforce Target: Analysis and Recommendations Part 1: Indigenous Health Workforce, NIHEC, Canberra.






There are difficulties relating to recruitment and retention of health care workers (of both Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander descent) to work in IHSs. Over half (57 per cent) of IHSs funded by OATSIH reported one or more staff vacancies in 2008-09. A significant proportion of positions (up to three-quarters) had reportedly been vacant for weeks, if not months.491

Evidence related to the Health Heroes campaign for secondary students

Lack of awareness about education and career pathways, and inaccurate perceptions about the amount of study required for health careers, are key barriers to attracting Aboriginal and Torres Strait Islander school students into health-related study and employment.492,493

The developmental research conducted for this measure found that interest and perceived relevance of health were key drivers to working in health for Aboriginal and Torres Strait Islander students. In addition, a perceived ability to support family, job security, income benefits, travel opportunities, and a desire to help the community and emulate respected individuals within the community with health jobs, were other identified benefits. These findings are supported by information from the National Aboriginal and Torres Strait Islander Health Equality Council stating a range of motivators are relevant to attracting students to health careers including personal motivators (e.g., recognition, respect), cultural and community motivators (e.g., drive to assist the community), and financial incentives.494 The developmental research undertaken for this measure recommended that communication campaigns aiming to increase the uptake of health jobs amongst students should focus on changing the existing knowledge, attitudes and behaviours held by Aboriginal and Torres Strait Islander students towards health jobs. Specifically, campaigns should ‘hook’ in the audience by appealing to their aspirations, focus on the benefits of health careers, provide information about the range of jobs available and provide relevant and correct information enabling people to pursue a job in health (e.g., study pathways). A focus on appeal and benefits is supported by other research about community campaigns in the Aboriginal and Torres Strait Islander context, which finds campaigns should focus on reducing barriers and build on existing motivators for change.495

491 Australian Institute of Health and Welfare 2010, Aboriginal and Torres Strait Islander health services report, 2008-09, OATSIH Services Reporting – key results, cat. no. IHW 31, AIHW, Canberra.492 National Indigenous Health Equality Council 2010, Health Workforce Target: Analysis and Recommendations Part 1: Indigenous Health Workforce, NIHEC, Canberra.493 Orima Research 2010, A report on developmental research to inform communications activities designed to attract more Aboriginal & Torres Strait Islander secondary school students to work in health, prepared for the Department of Health and Ageing, Orima, Australia.494 National Indigenous Health Equality Council 2010, Health Workforce Target: Analysis and Recommendations Part 1: Indigenous Health Workforce, NIHEC, Canberra.






Evidence related to the Do Something Real campaign for health professionals

The perceived benefits or attractive components of health careers differ for existing health professionals, and these factors should be considered for their relevance to promotional campaigns.A recognition of the importance of continuing professional education, and understanding and recognition of professional needs of staff, by employers, can be key factors making a job attractive and influencing sustained employment. Availability of training and support may also be key influencing factors. 496 Information from the National Aboriginal and Torres Strait Islander Health Equality Council suggests that, in addition to support and professional development opportunities, factors such as succession planning, prevention of burnout, recognition of community knowledge and obligations, cultural safety training, good remuneration and conditions, and workplace environment reform, are also key factors impacting the attractiveness of positions and the level of retention.497

Evidence related to effective community campaigns for Aboriginal and Torres Strait Islander audiences

The developmental research noted that multiple channels of communication are required for an effective campaign and that communication should be delivered by both Aboriginal and Torres Strait Islander, and other population groups. It should use simple formats and plain English, incorporate colour and visual components to aid understanding, and adopt an upbeat and positive tone.498 These findings are strongly supported in other research in this context, with relevant studies also identifying that campaigns tailored to local context499 and taking into account demographic characteristics and associated needs and preferences500 are more likely to be effective.

495 Ipsos-Eureka Social Research Institute & Winangali 2010, Developmental Research to inform the Local Indigenous Community Campaigns to Promote Better Health, prepared for the Department of Health and Ageing, Ipsos-Eureka, Sydney.496 Huntley B 1995, ‘Factors influencing recruitment and retention: why RNs work in rural and remote area hospitals’, Australian Journal of Advanced Nursing, vol. 12, no. 2, pp. 14-19.497 National Indigenous Health Equality Council 2010, Health Workforce Target: Analysis and Recommendations Part 1: Indigenous Health Workforce, NIHEC, Canberra.498 Orima Research 2010, A report on developmental research to inform communications activities designed to attract more Aboriginal & Torres Strait Islander secondary school students to work in health, prepared for the Department of Health and Ageing,Orima, Australia.499 Ipsos-Eureka Social Research Institute & Winangali 2010, Developmental Research to inform the Local Indigenous Community Campaigns to Promote Better Health, prepared for the Department of Health and Ageing, Ipsos-Eureka, Sydney.500 Sutherland A & Billimoria B 2011, Aboriginal and Torres Strait Islander continence training in rural and remote Australia. Conference paper presented at the 11th National Rural Health Conference, March 2011.






18.3 The central causal pathwayThe outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving enhanced workforce and service system capacity as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

Campaigns are effective, evidence based and

achieve desired exposure

Individuals and communities are

receptive to the message

Improvements in knowledge of and attitudes

towards jobs in health/Aboriginal and Torres Strait

Islander health

Health professional are more likely to seek

employment in IHS sector

More Aboriginal and Torres Strait Islander students

pursue further education and employment in the

health care sector

Attracting More People to Work in Indigenous Health

More Aboriginal and Torres Strait Islander people

become health professionals



Students are motivated and supported

Students are supported and provided with opportunities

to complete training and gain employment

Changes in knowledge and attitudes lead to changes in behaviour

IHSs are able to employ additional health

professionals

Figure 23: Attracting More People to Work in Indigenous Health (C4) measure causal model. Source: KPMG. 18.4 Reach and timeframes The potential reach501 of the measure will be determined by factors including the exposure of the promotional campaigns and the extent to which the campaigns successfully engage the target audiences.Early results for the Health Heroes campaign, occurring from years two to four, are expected to include increased understanding and positive perceptions of career opportunities in the health sector among Aboriginal and Torres Strait Islander students, and increased enrolment in health care-related higher







education. Over the same period, the Do Something Real promotional campaign is expected to result in increased understanding of opportunities to work in the IHSs sector among established and training health care professionals, as well as increased recruitment of health professionals into IHSs. As a medium term result (four years and longer), the measure is expected to yield increased and sustained participation of Aboriginal and Torres Strait Islander people in the health care workforce, and health professionals overall in the IHSs sector workforce. 18.5 Complementary activityA number of other ICDP measures are similarly interested in workforce development – particularly the Workforce Support, Education and Training (C1) measure; however, the Attracting More People to Work in Indigenous Health (C4) measure is not directly linked to activities in other measures. Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. A number of other national mainstream and state and territory initiatives are also working towards addressing workforce issues in the IHS sector. Appendix B provides Policy Maps which identify these complementary activities. 18.6 Attracting More People to Work in Indigenous Health data

sourcesEvaluation of this measure will be informed by a range of primary data sources including: consultation with departmental stakeholders; community consultations; health workforce and organisational surveys; and analysis of program documentation.In terms of secondary data sources, OATSIH Services Reports (OSR) will, in year four (2012-13), inform on whether health professionals are increasing their participation in the IHS sector, and whether IHSs find it easier to recruit qualified health professionals. In addition to these sources, a number of other secondary data sources are used in this report to assess historical trends and progress against Attracting More People to Work in Indigenous Health (C4) measure evaluation framework indicators at the commencement of the measure. These include: National Centre for Vocational Education and Research (NCVER) data; and Data from the Department of Education, Employment and Workplace

Relations (DEEWR)A discussion of these secondary data sources and their limitations is provided in Appendix E. The Evaluation Framework502 identifies several indicators to measure the whole of Package which are directly relevant to this measure. These are:









Aboriginal and Torres Strait Islander peoples’ enrolment in health-related higher education courses/VET courses, as reported in section 3.18 of the HPF. In 2010, the number of these students enrolled was 2,119.

Number of Aboriginal and Torres Strait Islander people in the health workforce, as reported in section 3.10 of the HPF. In 2006, this was 5,483.

Size of the workforce within Indigenous Health Services, as reported in section 3.20 of the HPF. In 2009-10, the number of FTE staff within Aboriginal and Torres Strait Islander primary health care services funded by the Australian Government was 4,835 which is composed of 2,745 Aboriginal and Torres Strait Islander staff, and 2,090 non-Indigenous staff.

Refer to Appendix F for further information about these indicators, including original sources. The evaluation will monitor and provide updates on these indicators as they become available.18.7 Year one progress

Key activities

The major activity of the Attracting More People to Work in Indigenous Health (C4) measure conducted in the first year of implementation (2009-10) was the research project conducted into the knowledge, attitudes, behaviours and intentions of Aboriginal and Torres Strait Islander students to work in the health sector. The final research report from this project was provided to the department on 28 June 2010.503 Building on the developmental research, during 2009-10 the first round of community engagement sessions for the Health Heroes campaign took place in New South Wales, Victoria, Queensland and South Australia. The consultant delivering the community engagement activity proposed this approach as it had existing networks in these areas, which would assist in ensuring the effective delivery of the first round of community engagement sessions. In addition, a procurement process commenced in May 2010 to engage a consultant to develop the Do Something Real campaign.Three performance indicators for this measure are included in the Commonwealth Implementation Plan: Number of tertiary education seminars conducted. Website usage data. Number and type of culturally relevant information products disseminated to

health professionals, schools and universities.504

503 Orima Research 2010, A report on developmental research to inform communications activities designed to attract more Aboriginal & Torres Strait Islander secondary school students to work in health, prepared for the Department of Health and Ageing, Orima, Australia.504 Commonwealth of Australia 2008, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, Commonwealth of Australia, Canberra.






As described above, gains were made against the first of these three indicators, with the remaining two indictors to become areas of focus in 2010-11. In 2009-10, actual expenditure was $388,456.

Historical trends and progress against indicators in year one

Secondary data that was collected prior to or during the 2009-10 year provides information about patterns and emerging trends relating to current participation in the Aboriginal and Torres Strait Islander health care sector, and participation in health-related education by Aboriginal and Torres Strait Islander students.Through the OATSIH Services Reporting process, IHSs report on the current vacancies in clinical and other positions within their organisation. At the end of 2009-10, just over half (55 per cent) of all OATSIH funded IHSs reported having one or more staff vacancies — a total of 295 FTE positions. This was similar to the previous year (57 per cent or 296 FTE). Further summary statistics are presented in Table 31 below.Table 31: Selected OSR statistics on vacancies in community controlled IHSs.505

Service type Summary statistic 2008-09 2009-10Aboriginal and Torres Strait Islander primary health care services

Total FTE vacancies 296 295

Aboriginal and Torres Strait Islander primary health care services

Total FTE vacancies as percentage of total workforce

7% 6%


Percentage of vacancies that were vacant for 50 weeks or more

23% 34%


Percentage of vacant positions that were Aboriginal and Torres Strait Islander health workers

23% 23%


Percentage of vacant position that were in remote areas

20% 30%



505 Australian Institute of Health and Welfare 2011, Aboriginal and Torres Strait Islander health services report 2009–10: OATSIH Services Reporting — key results, cat. no. IHW 56. Canberra, AIHW.






Service type Summary statistic 2008-09 2009-10



2% 3%



11% 30%

Bringing Them Home and Link Up counselling services




22% 18%



38% 28%

As this table shows, vacancies have remained relatively steady over the last two years. However at the same time, the workforce has increased within community controlled IHSs: in 2008-09 there were 4,318 FTE staff, and in 2009-10 this number had increased by 12 per cent to 4,841 FTE staff.This data suggests that the number of vacancies is not growing at the same rate as the total number of people in the workforce. As illustrated in Figure 24 below, the number of all students enrolled in health disciplines in the vocational sector across Australia has remained relatively stable over recent years.






Figure 24: Aboriginal and Torres Strait Islander vocational education students enrolled in health disciplines across Australia, 2008-10.506

Approximately 4,000 students were enrolled in health disciplines between 2008 and 2010. Over this same period all student enrolments grew by around 17,000; from 80,322 in 2008 to 97,472 in 2010. This suggests that enrolments in health disciplines are not increasing at the same rate as enrolments overall. Figure 25 below presents data on Aboriginal and Torres Strait Islander university students enrolled in health disciplines across 2008-10.

506 Based on data supplied by NCVER.236





Figure 25: Aboriginal and Torres Strait Islander university students enrolled in health disciplines.507

As Figure 25 shows, within the tertiary sector there has been an increasing trend in enrolments in the health discipline by Aboriginal and Torres Strait Islander between 2008 (1,689 students) and 2010 (2,114 students).

507 Based on data supplied by DEEWR. 237





19. Clinical Practice and Decision Support Guidelines

Clinical Practice and Decision Support Guidelines (C5) measure at a glanceICDP priority area: Fixing the gaps and improving the patient journey.The issue being addressed: Use of high quality clinical practice guidelines can lead to improved patient care and clinical governance. There is an opportunity to improve consistent access to high quality clinical practice guidelines by collating and presenting them in a single web-based resource.The ICDP solution: This measure seeks to develop a web-based resource which consolidates information relevant to clinical care for Aboriginal and Torres Strait Islander patients with chronic disease in order to support the provision of higher quality patient care. The supporting evidence: There is evidence to suggest that use of clinical guidelines in conjunction with other supports leads to improved service delivery508 and enhanced management of chronic disease. 509,510,511 Given that Aboriginal and Torres Strait Islander people are likely to present with acute and complex needs, there is a strong rationale for providing support to clinicians with relevant clinical guidelines. The central causal pathway: This measure provides easy access to clinical practice and decision support resources with an aim to increase the knowledge, understanding and skills of clinicians providing chronic disease management to Aboriginal and Torres Strait Islander people. It is proposed that this will lead to an increase in better practice management of chronic diseases. Reach: The potential and actual reach of the measure will be determined by the availability of the web-based resource; particularly given that not all clinicians may have reliable access to the internet at the point of care, and also by the uptake and use of the resource by clinicians. As at 2009-10 there were no specific targets for access to the resource by the target audience (i.e., the website user count). Timeframes: In the shorter term (defined here as two to four years) it is expected that clinicians will increasingly access to utilise clinical practice and

508 Bailie RS, Tongi SJ, Si D, Robinson G & d’Abbs PHN 2003, ‘Preventative medical care in remote Aboriginal communities in the Northern Territory: a follow up study of the impact of clinical guidelines, computerised recall and reminder systems and audit and feedback’, BMC Health Services Research, vol. 3, no. 15, pp 1-13.509 McDermott R, Tulip F, Schmidt B & Sinha A 2003,’Sustaining better diabetes care in remote indigenous Australian communities’, British Medical Journal, vol. 327, no. 7412, pp. 428-430. 510 Weeramanthri T, Connors C, O’Leart S, Yamirr D, Wright J & Bell A 2002, ‘Chronic disease guidelines and the Indigenous Coordinated Care Trials’, Australian Health Review, vol. 25, no. 2, pp1-6. 511 Pilla J 2002, ‘Giving support to disease guidelines’, Australian Health Review, vol. 25, no. 2, pp 7-10.






decision support guidelines, and in the longer term the good practice encouraged by use of these resources may become sustained and embedded. Year one progress: In the first year of the measure’s implementation (2009-10) the key activity completed was a review of the literature and existing guidelines, tools and resources. This resulted in the Technical Reference Group advising the department to focus the measure on collating existing resources rather than developing new resources to support clinical practice. 19.1 Design of the Clinical Practice and Decision Support Resources

(C5) measureThe Clinical Practice and Decision Support Guidelines (C5) measure provides access to a web-based resource containing a range of information and practice resources relevant to the prevention and management of chronic disease amongst Aboriginal and Torres Strait Islander people. Information in the resource will be available to mainstream and IHS primary health care practices across Australia through clinical information systems (e.g., Medical Director) and will also be publicly available online. Resources, including clinical practice guidelines, tools and patient education materials have been selected for inclusion in the initial release of the web-based resource. The web-based resource will consolidate the resources in one location to facilitate easy access to relevant resources and information. The Clinical Practice and Decision Support Guidelines (C5) measure involves: pilot testing the web-based resource with primary health care providers; working with the Royal Australian College of General Practitioners (RACGP)

and vendors to ensure that the resource is easy to access from clinical information management systems (e.g., Medical Director); and

commissioning an organisation to develop a production version of the resource, to maintain the content and to promote its uptake amongst primary health care providers.

The web-based resource will be available nationally to primary health care practices and will be promoted by the commissioned organisation, as well as the department and peak organisations such as the RACGP.The measure also includes an additional evaluation component - the two pilot studies for implementation of the web-based resource were conducted by Hewlett Packard; each of which produced a pilot report.Since early 2009, the design and implementation of the measure was guided by a Technical Reference Group established specifically for this initiative. This group brought together a range of experts in Aboriginal and Torres Strait Islander health, chronic disease management, primary health care, evidence-based medicine and clinical guidelines. The membership of the group comprised nominated representatives of specified organisations, including both mainstream organisations such as the RACGP, National Heart Foundation and Cancer Australia, and Aboriginal and Torres Strait Islander organisations such as NACCHO and CATSIN, and has changed over time. The Technical Reference






Group, having fulfilled its role, has been wound up but it is expected that a similar group will be convened by the contractor (to be commissioned) to assist in developing and maintaining the production version of the web-based resource.The measure has a budget of $3.14 million over four years 2009-10 to 2012-13.

Stakeholders

Stakeholders for this measure include internal and external parties at the local/community, jurisdictional and national levels. Table 32 below provides an overview of the key stakeholder groups and their role in relation to the Clinical Practice and Decision Support Guidelines (C5) measure.Table 32: Key stakeholders and roles in relation to the Clinical Practice and Decision Support Guidelines (C5) measure.512

Stakeholder Role in the Clinical Practice and Decision Support Resources measure


Contract organisations to develop the web-based resource and other support materialsCoordinate input from other key stakeholders

Department State / Territory Offices

No direct role, but may have a role in promoting the application

Technical Reference Group

Provide recommendations on the design and implementation of the web-based resourceSelect resources for inclusion in web-based resource

Royal Australian College of General Practitioners

Produce a 2nd edition national guide to a preventative health assessment for Aboriginal and Torres Strait Islander peopleMember of the Technical Reference GroupFund GP practices to have access to a proprietary tool that will contain the link to the application, so that access is integrated into their practice software

Hewlett Packard Develop the web-based resourcePrimary health care practices involved in pilot studies

Participate in pilot project and associated evaluation

Primary health care providers Primary intended users of web-based resource

Consumers / general public Secondary / ancillary users







Measures within the ICDP are expected to adhere to the six service delivery principles of the Council of Australian Governments’ (COAG) Closing the Gap National Indigenous Reform Agreement (NIRA).513 The description below provides the definition for each of the NIRA principles and identifies how they have been applied to the Clinical Practice and Decision Support Guidelines (C5) measure. Priority: Programs and services should contribute to Closing the Gap by meeting the targets endorsed by COAG while being appropriate to local needs. The measure supports the core aims and targets of Closing the Gap given its

focus on improving chronic disease management care through the provision of guidelines, tools and patient education materials. The specific expected contribution is increased capacity for primary health care providers to deliver appropriate care to Aboriginal and Torres Strait Islander people.

Because of the broad range of resources expected to be included in the web-based resource, it is likely it will have broad appeal and value.

Indigenous engagement: Engagement with Indigenous men, women and children and communities should be central to the design and delivery of programs and services. This measure involved various Aboriginal and Torres Strait Islander

organisations in the development of the web-based resource including NACCHO, AIDA and CATSIN via the Technical Reference Group.

Patient education materials included in the web-based resource may improve communication and engagement between primary health care providers and Aboriginal and Torres Strait Islander patients.

Sustainability: Programs and services should be directed and resourced over an adequate period of time to meet the COAG targets. The measure id funded over the first four years – 2009-10 to 2012-13 for the

design, development and ongoing support of the web-based resource through to the end of the ICDP timeframe. However, once developed the resource will be accessible in an ongoing way (i.e., beyond the first four years of ICDP funding).

Access: Programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs. The primary intended users of the application are primary health care

providers including clinicians and Aboriginal Health Workers. The application is being designed to suit the needs of each provider group, who were involved in the pilot testing of the application.

The application will also be available to all individuals, Aboriginal and Torres Strait Islander people and other Australians through the internet. However, it is important to note that, because not all people are likely to have access to the internet, particularly in remote areas, access may be impacted for a small









subset of the target populations. Materials included in the web-based resource have not been adapted for greater accessibility – i.e., use of plain language or other communication strategies.

Integration: There should be collaboration between and within government at all levels and their agencies to effectively coordinate programs and services. The design of the web-based resource and the selection of its content has had

considerable input from peak bodies including clinical groups and NACCHO to ensure that the application includes all relevant content and other resource tools.

Further, the contractor to be commissioned to develop the production version of the resource will be required to establish a reference group to ensure that there is ongoing collaboration with these organisations to maintain the content.

Note, at 2009-10 there had been little explicit consideration given to coordinating the release and promotion of the application with other measures that have a significant primary health care workforce component.

Accountability: Programs and services should have regular and transparent performance monitoring, review and evaluation. The Clinical Practice and Decision Support Guidelines (C5) measure is

included in two ICDP evaluation projects – the Indigenous Chronic Disease Package National Monitoring and Evaluation Project (this project) and the Sentinel Sites Evaluation

The contractor to be commissioned to develop and maintain the production version of the resource will be subjected to normal contractual performance reporting and will be required to establish a reference group to ensure that the application remains relevant to end users.

19.2 Rationale and supporting evidenceAboriginal and Torres Strait Islander people have specific needs for chronic disease care and management due to a range of factors such as prevalence of co-morbidities, geographical remoteness and the need for culturally appropriate care.514 Health professionals require support and guidance to deliver effective care to this population.515

Evidence related to the use of web-based primary health care resources

The use of web-based resources by health professionals is an increasing area of research interest.

514 Steering Committee for the Review of Indigenous Service Provision2007, Overcoming Indigenous Disadvantage Key Indicators 2007, Report, Commonwealth of Australia, Canberra.515 Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Powell Davies G & Hasan I 2006,A Systematic Review of Chronic Disease Management, Australian Primary Health Care Research Institute, Canberra.






Data from the Australian General Practice Statistics and Classification Centre for 2007-2008516 shows that only 3.3 per cent of GPs worked in a non-computerised practice during this period, with nearly four-fifths of practices having access to the internet and/or email. This means that the majority of GPs (key primary health care providers) are likely to be able to access a web-based resource. A study surveying GPs in New Zealand517 identified key benefits of use of internet-based resources including increased access to rapid and flexible health information, ability to access health information from work or home, and ability to access online education and training. However, barriers to use of the internet by GPs, particularly in rural and remote locations, include lack of access to computers and fast internet, lack of time to incorporate internet use within day-to-day practice, concerns about information technology (IT) costs and security, lack of energy/motivation to learn new skills and competing priorities such as family.518,519,520 Health professionals commonly identify a preference for modalities that include more social interaction521, and state that use of the internet may risk ‘losing the human touch’ within primary care practice.522,523 Within the context of increasing access to broadband, a key barrier identified for health professionals is self-reported lack of IT skills 524, and difficulties finding quality information.525

516 Australian GP Statistics and Classification Centre 2008, General practice activity in Australia 2007-08, AIHW and the University of Sydney, Sydney. 517 James R, Arroll B, Buetow S, Coster G, McCormick R & Hague I 2005, ‘Rural New Zealand health professionals’ perceived barriers to greater use of the internet for learning ‘, The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy, vol. 5, no. 436 (online).518 Illingworth P. 2002 ‘Trust: the scarcest of medical resources’, Journal of Medicine and Philosophy, vol. 27, pp 31-46.519 Shepparton L & Mackintosh S 2008, ‘Technology in education: what is appropriate for rural and remote allied health professionals?,’ Australian Journal of Rural Health, vol. 6, no. 4, pp. 189-193.520 Zaks D, Schattner P & Klein B 2007, ‘Promoting GP use of the Internet for evidence based practice: evaluation of an education program’, Electronic Journal of Health Informatics, vol. 2, no. 2, e13.521 James R, Arroll B, Buetow S, Coster G, McCormick R & Hague I 2005, ‘Rural New Zealand health professionals’ perceived barriers to greater use of the internet for learning ‘, The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy, vol. 5, no. 436 (online).522 Shepparton L & Mackintosh S 2008, ‘Technology in education: what is appropriate for rural and remote allied health professionals?,’ Australian Journal of Rural Health, vol. 6, no. 4, pp. 189-193.523 Zaks D, Schattner P & Klein B 2007, ‘Promoting GP use of the Internet for evidence based practice: evaluation of an education program’, Electronic Journal of Health Informatics, vol. 2, no. 2, e13.524 Zaks D, Schattner P & Klein B 2007, ‘Promoting GP use of the Internet for evidence based practice: evaluation of an education program’, Electronic Journal of Health Informatics, vol. 2, no. 2, e13.525 James R, Arroll B, Buetow S, Coster G, McCormick R & Hague I 2005, ‘Rural New Zealand health professionals’ perceived barriers to greater use of the internet for learning ‘, The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy, vol. 5, no. 436 (online).






There is evidence to suggest that, in conjunction or association with other initiatives such as training, recall and reminder systems and support, the use of clinical guidelines leads to improved service delivery526 and enhanced management of chronic diseases such as diabetes.527

Evidence related to implementation and uptake of clinical guidelines

Two articles reflecting on the implementation of clinical support guidelines through the Aboriginal and Torres Strait Islander Coordinated Care Trials528 suggest that the following are key factors supporting sustained uptake of guidelines within the IHS sector: guidelines linked to computer information systems that translate them into

items of service and present them to the health worker at the time of consultation;

guidelines that are flexible to account for the likely differences between organisations in capacity and practice;

guidelines that, where possible, are implemented in a receptive service environment (i.e., staff are willing to engage and/or experienced in using guidelines), or in the context of a receptive model such as the Coordinated Care Trials; and

guidelines that, where possible, can be integrated into existing practice/organisational structures and systems.

Other factors influencing uptake of clinical guidelines have been identified through research. For example Zaks et al.529 found that familiarity with one or a small number of web-based resources may increase the likelihood of web-based resource use more broadly (which may occur over time or with staged or targeted implementation of clinical support systems). Bailie et al.530 found a positive relationship between the number of AHWs within primary health care practices and the delivery of guideline-scheduled care for chronic disease. This study found that the higher the number of AHWs, the more likely that guidelines

526 Bailie RS, Tongi SJ, Si D, Robinson G & d’Abbs PHN 2003, ‘Preventative medical care in remote Aboriginal communities in the Northern Territory: a follow up study of the impact of clinical guidelines, computerised recall and reminder systems and audit and feedback’, BMC Health Services Research, vol. 3, no. 15, pp 1-13.527 McDermott R, Tulip F, Schmidt B & Sinha A 2003, ‘Sustaining better diabetes care in remote indigenous Australian communities’, British Medical Journal, vol. 327, no. 7412, pp. 428-430. 528 Weeramanthri T, Connors C, O’Leart S, Yamirr D, Wright J & Bell A 2002,’Chronic disease guidelines and the Indigenous Coordinated Care Trials’, Australian Health Review, vol. 25, no. 2, pp1-6, and Pilla J 2002 ‘Giving support to disease guidelines’, Australian Health Review, vol. 25, no. 2, pp 7-10.529 Zaks D, Schattner P & Klein B 2007, ‘Promoting GP use of the Internet for evidence based practice: evaluation of an education program’, Electronic Journal of Health Informatics, vol. 2, no. 2, e13.530 Bailie RS, Tongi SJ, Si D, Robinson G & d’Abbs PHN 2003, ‘Preventative medical care in remote Aboriginal communities in the Northern Territory: a follow up study of the impact of clinical guidelines, computerised recall and reminder systems and audit and feedback’, BMC Health Services Research, vol. 3, no. 15, pp 1-13.






were used – either suggesting a relationship between the use of best practice guidelines and: the presence of health care staff in higher numbers; the presence of Aboriginal and Torres Strait Islander health care staff; and/or the presence of staff with lower levels of qualifications (i.e., compared to GPs

and nurses).

Evidence related to content for Aboriginal and Torres Strait Islander people

The literature on the components of effective Aboriginal and Torres Strait Islander-focused clinical guidelines is limited. Findings of a review of the brief intervention resource kits designed to address SNAP risk factors531 (smoking, poor nutrition, alcohol misuse, physical inactivity) may provide some insight relevant to the selection of tools for the Clinical Practice and Decision Support Guidelines (C5) measure. This review found that resources considered appropriate in content and format for Aboriginal and Torres Strait Islander-specific care provision included: a training package to support health professionals in delivering care, for

example in using the resources in a culturally appropriately way; patient education material such as brochures; behavioural change strategies for example ‘stages of change’; and images and language identifiable with Aboriginal and Torres Strait Islander

people. 19.3 The central causal pathway The outcomes which this measure aims to achieve should occur over the short, medium and long term, and are influenced by factors within and outside of the measure. The expected steps that should occur in achieving better management of chronic disease as a result of the activities of this measure represent a ‘causal pathway’. The diagram below reflects KPMG’s interpretation of the central causal pathway inferred be the measure’s design. It illustrates: the theoretical basis for this measure through a causal chain of expected or desired outcomes/results over a period of time (dark text bubbles linked by arrows); and the key dependencies and assumptions that must be present to allow these outcomes/results to be achieved and build upon each other (light text boxes).

531 Clifford A, Jackson Pulver L, Richmond R, Shakeshaft A & Ivers R 2010, ‘Brief intervention resource kits for Indigenous Australians: generally evidence-based, but missing important components’, Australian and New Zealand Journal of Public Health, vol. 34, no. S1, pp. s80-s86.






Clinical Practice and Decision Support

Guidelines


and skills

Increase in better practice management of chronic

disease



Providers know how to access the resources

Providers access and engage with

the resources

Providers utilise the resources appropriately

Resources are fit for purpose

Resources are fit for purpose

Figure 26: Clinical Practice and Decision Support Resources measure causal model. Source: KPMG. 19.4 Reach and timeframesThe potential reach532 of the measure will be determined by factors including the availability of the web-based resource – particularly given that not all clinicians may have reliable access to the internet at the point of care – and the uptake and use of the resource by clinicians. As at 2009-10 there were no specific targets for access to the resource by the target audience (i.e., the website user count).As an early result (years two to four), the measure is expected to result in primary care providers having increased access to clinical practice guidelines, tools and patient education materials relevant to chronic disease management for Aboriginal and Torres Strait Islander patients, and having increased their application of clinical practice guidelines, tools and patient education materials to chronic disease management for Aboriginal and Torres Strait Islander patients. As a medium term result (four or more years) the measure is expected to result in increased and sustained use of clinical practice guidelines, tools and patent education materials for chronic disease management for Aboriginal and Torres Strait Islander patients. 19.5 Complementary activityThe evaluation has not identified other work being done to collate and provide clinical tools specific to Aboriginal and Torres Strait Islander chronic disease management; however, the measure itself builds on previous work undertaken by numerous stakeholders to develop the tools that will comprise the web-based resource. Within the ICDP itself this measure is not directly linked to others, however, the measure supports other measures which also seek to improve chronic disease management through enhancing the workforce or coordination. Specifically, providers who may utilise the resources may also work with the PIP Indigenous Health Incentive (B3a) and USOAP and MSOAP-ICD (B5) measures. The web-based resource could also include relevant resource materials developed by other measures (such as the provision of support and training to health professionals to deliver Chronic Disease Self Management sessions to







Aboriginal and Torres Strait Islander patients under the Chronic Disease Self Management (B4) measure). The ICDP workforce and related measures could also have a role in promoting use of the resource, for example, through the activities of IHPOs to increase the capacity of the health workforce in IHSs and mainstream practices to provide better practice care. There are opportunities to promote the web-based resource not just through the ICDP but also through the COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes activities being funded by other jurisdictions, as well as other quality improvement and chronic disease management programs being funded by the department. Refer to Appendix C for more information on the key synergies between the different measures of the ICDP. 19.6 Clinical Practice and Decision Support Guidelines dataEvaluation of this measure will be informed by a range of primary data sources including consultation with primary health care providers and the former Technical Reference Group, the health workforce survey and website user survey, and review of program documentation. 19.7 Year one progress The original focus of the Clinical Practice and Decision Support Guidelines (C5) measure was the adaptation of existing clinical practice guidelines for the management of chronic disease for Aboriginal and Torres Strait Islander people. To this end, preliminary scoping work for the measure in its first year of implementation (2009-10) included a review of the literature and existing guidelines, tools and resources, and the establishment of, and consultation with, the Technical Reference Group. At the conclusion of this preliminary analysis, the department accepted the Technical Reference Group’s recommendation that increasing provider access to existing resources would provide greater value than adapting existing clinical practice guidelines. Moreover, the Technical Reference Group considered that existing guidelines were suitable for use by primary health care providers when servicing the needs of Aboriginal and Torres Strait Islander people.The Technical Reference Group developed and applied criteria for selecting resources to be included in the web-based resource. The Technical Reference Group also discussed needs for maintaining the relevance and currency of the resource. The Technical Reference Group met three times in 2009-10. Hewlett Packard was engaged through an open market tendering process, to build and pilot an initial version of the resource and populate it with the demonstration content. The contract for this engagement was signed on 17 June 2010. In addition to building and piloting the initial resource, the company






incorporated a proprietary product referred to as the ‘sidebar’533, which enables the application to link to clinical information systems. In 2009-10, the actual expenditure on the Clinical Practice and Decision Support Guidelines (C5) measure was $1.194 million. Some funding was provided to contract the RACGP to develop a second edition of the national guide to a preventative health assessment for Aboriginal and Torres Strait Islander people.

The contract for the maintenance of the resource needs to include sufficient provision to ensure that the content is maintained and to include an allowance for further modification as the experiences of end users mature.The Commonwealth Implementation Plan534 identifies one performance indicator for the Clinical Practice and Decision Support Guidelines (C5) measure, which refers to the expected output: “clinical practice and decision support guidelines developed and disseminated.” However, since the measure no longer includes development of resources, the indicator has been modified to “website user count.”535 As the web-based resource had not been developed and disseminated in 2009-10, there are no results to report (including no available website user count data) against this indicator.

533 The PrimaryCareSidebar™ delivers a standard eHealth resource onto the computer desktops of primary care providers. Providing a range of valuable clinical tools and resources at the fingertips of clinicians, the PrimaryCareSidebar™ eases existing work flows while facilitating the delivery of best care for patients, ‘Introducing PrimaryCareSidebar’ , viewed October 2011.534 Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Jurisdiction: Commonwealth, viewed 7 September 2012.535 Based on information provided by the Department of Health and Ageing.






http://www.pencs.com.au/product-sidebar-overview.html