6.2. Australian models of integrated care
6.2.5. Aboriginal and Torres Strait Islander organisations and models that influence
PHC for Aboriginal and Torres Strait Islander people is of particular concern to the campaign to ‘close the gap’ in health between Aboriginal and non-Aboriginal Australians. The Australian government funds indigenous-specific PHC; and the State/Territory governments contribute funding and deliver a range of services, including Indigenous-specific services (see Table 16 (Appendix A). Effectiveness of integration initiatives to improve health service delivery is discussed in Report 5 (Integrated care:
What can be done at the micro level to influence integration in primary health care?), whereas this section discusses meso level integration involving collaborations between organisations to facilitate integration of services for Indigenous Australians.
Aboriginal Community Controlled Health Services
While Indigenous Australians can access both mainstream and indigenous-specific health care services, it is important that these two systems work together to provide good quality health care;
and that they take steps to close the gap in health between Indigenous and non-Indigenous Australians.
Often considered as a standalone aspect of PHC (see Box 1), Aboriginal Community Controlled Health Services (ACCHS) are examples of highly effective integrated services (described in detail in Report 5xiv). In each state and territory, there is a peak body representing the interests of their area’s ACCHS. These are meso level organisations, connecting and promoting communication between different ACCHS. They are the ‘health voice’ for all Aboriginal people in a certain area, and play an advocacy role supporting both the health workers and the community, promoting integrated Aboriginal health services in their local areas (National Aboriginal Community Controlled Health Organisation, 2013). For example, the Aboriginal Medical Services Alliance Northern Territory (AMSANT) is the peak body for ACCHS in the Northern Territory. AMSANT represents the interests of ACCHS in various forums, including policy, funding, and administrative matters pertaining to
Aboriginal health disadvantage.
xiv Integrated care: What can be done at the micro level to influence integration in primary health care?
The Central Australian Aboriginal Congress, formed in 1973, is one of the oldest and largest ACCHS delivering comprehensive PHC in Australia (Bartlett and Boffa, 2001); and is an example of a peak body which utilises the comprehensive PHC philosophy. Comprehensive PHC focuses on all levels of the health system including mechanisms at the organisational level for creating capacity in the workforce and enabling community empowerment around health issues. Comprehensive PHC also plays a role in advocacy role and policy development at the macro level. At the service delivery end of healthcare systems, comprehensive PHC focuses on providing effective, efficient, and appropriate comprehensive PHC for Aboriginal people and spans different levels of system integration (vertical).
Congress Alukura is an ACCHS that provides a range of culturally appropriate women’s health services in a PHC model (Carter et al., 2004). Alukura was established in 1987 following extensive community consultation with 60 different Aboriginal communities and 11 different language groups.
Alukura aims to preserve and recognise Aboriginal identity, culture, law and languages, especially as they relate to “borning matters, pregnancy, childbirth and the care of women and their infants”
(Carter et al., 2004, p 229).
In addition to services related to birthing and infant care (antenatal and postnatal care, shared maternity care), Alukura also provides a range of other important women’s services including:
gynaecological services, sexual assault and domestic violence counselling, health education; and other services (transportation, health worker training, bush mobile clinic).
A review of Alukura was undertaken in 1998 (cited in Carter et al., 2004), not only to assess how well the congress met the needs of local Indigenous women, but also assessed the relationships with other health care providers and their organisational capacity to meet the objectives. The review reported an increase in the proportion of women attending antenatal care in the first trimester;
increased average weight of babies; and perceptions of high quality of care received.
Since the assessment, Congress Alukura and Alice Springs hospital have developed a memorandum of understanding that allows Alukura’s accredited midwives to offer continuity of care to clients giving birth in the hospital. This allows midwives to develop their skills in complicated births.
In contrast to Northern Territory, where less than 20 per cent of the Indigenous population live in urban areas, less than one per cent of the Victorian Indigenous population live outside urban areas (Baeza and Lewis, 2010). This requires a different approach to health care service delivery as there is less access to indigenous-specific services and a greater need for indigenous and mainstream services to work together. ACCHS play a role not only in providing culturally appropriate health care services, but also in educating mainstream services to develop more culturally appropriate care and to work more closely with Indigenous populations. An evaluation report of ACCHS was not available.
Specialist outreach services and clinics
While PHC is the first point of access for most people, the Indigenous population suffer from many conditions that contribute to their lower life expectancy and require specialist attention. However, geographic distance to PHC, lack of public transport, cost of travelling to hospital outpatient appointments and poor communication between hospitals and remote clinics are barriers to accessing specialist services for many Indigenous Australians (Gruen and Bailie, 2004). A specialist outreach service was introduced in 1997 to address the gap in services to remote communities. This service entailed cooperation between a range of different specialties (e.g. gynaecology,
ophthalmology, otolaryngology, general surgery); administrative staff to organise transport,
accommodation and appointments; and hospital services to follow up on more complex procedures.
In contrast to many other outreach services in different areas (e.g. UK, which simply provide more convenient access for patients) (Powell, 2002), integrated specialist outreach clinics in remote parts of Australia provide services that patients would otherwise not be able to access at all (without specialist outreach clinics, 30% of patients referred to a specialist never completed their referral) (Gruen and Bailie, 2004).
Similarly, a specialist cardiac Indigenous outreach service was established in rural and remote Queensland (Tibby et al., 2010). In 2005, a partnership was established between the Prince Charles Hospital and the Central Area Cardiac Clinic Network in Queensland to deliver outreach cardiac health care services directly to rural and remote communities in Queensland, without the need for a referral through a PHC provider. The service specifically targeted Indigenous communities and aimed to develop strong relationships with the Indigenous population by engaging Indigenous health care workers to identify those in need of cardiac specialist services. Tibby et al. (2010) suggest that sustainable improvement in cardiac Indigenous health will require a “synchronised multi-pronged approach” with other agencies, such as housing, sport and recreation, and community councils to address determinants of health and to maximise a harmonious working relationship between
Western medical technology and traditional Aboriginal values of health and wellbeing. No evaluation reports for these services were available.
A framework for primary health care in the NT
The Northern Territory Aboriginal Health Forum (Tilton and Thomas, 2011) identified several factors that impact on delivery of good quality, well-integrated and culturally appropriate health care for Indigenous populations living in remote and rural areas of Australia, including:
Availability of services: distance, lack of transport, poor roads, costs (getting to clinic, treatment/medication costs), cultural safety of services
Coordination of care: limited service infrastructure puts pressure on PHC to integrate services (e.g. facilitating transitions between hospital and community; ensuring access to diagnostic, treatment, rehabilitation or palliative care services)
Multidisciplinary care teams: Aboriginal health workers, nurses, GPs, medical specialists and allied health professionals
Adequacy of resources and workforce: in communities where there is high prevalence of complex conditions, complicated by culturally specific needs, there is a need for adequate staff and resources to allow sufficient time to deliver integrated care that may involve both clinical and non-clinical services.
A framework for PHC in the Northern Territory was developed in a partnership between the Australian Commonwealth government, the NT government and the Aboriginal Medical Services Alliance (Tilton and Thomas, 2011). The framework is the result of a highly consultative process with experienced practitioners, researchers, service delivery organisations and policy makers. PHC, as intended in the framework, refers to complex, holistic, first-level health care that “emphasises community participation, intersectoral collaboration and integration, and as a strategy for reorienting the way a health system works” (Tilton and Thomas, 2011, p 5). The framework comprises five domains:
clinical services
health promotion
corporate services and infrastructure
advocacy, knowledge and research, policy and planning
community engagement, control and cultural safety.
While clinical services, health promotion and advocacy are delivered directly to individuals and/or the Aboriginal community, the support functions (corporate services, policy and planning) and enabling functions (community engagement, control and participation, cultural safety and use of knowledge and evidence to inform practice) operate at the meso and macro levels of integration.
Tilton and Thomas (2011) suggest that the strong interrelationships between the domains demand not only close connections between those working in the different areas, but also require staff to have a good understanding of, and to work across the domains. For example, to effectively deliver culturally safe, integrated health care services, care teams are expected to work with health promotion programs; engage, recruit, train and support staff appropriately; contribute to planning processes; and be informed by knowledge and evidence to determine the most appropriate mix of services.
The authors of the framework also identified four areas that are important to Indigenous PHC, but that are poorly integrated into comprehensive PHC. These are: alcohol, tobacco and other drugs;
early childhood development and family support; aged and disability; and mental health/social and emotional health and wellbeing.
A key function of the framework is to create a supportive environment by directing health promotion efforts away from changing individual behaviour, which is ineffective and potentially counterproductive, towards integrating health promotion principles in organisational policies and practices. Examples include policies that promote non-smoking, no ‘grog’, and healthy catering for health service functions (Tilton and Thomas, 2011). No evaluation of the framework was available.
Health Action Teams (HATs)
Health Action Teams (HATs) are local health advisory groups that have been established in several remote Aboriginal communities in Queensland (Kowanyama, Coen, Lockhart River and Apunipima in Cape York) (Laverack et al., 2009, Coombe et al., 2008). Their goal is to “build community capacity for Indigenous people to take control of and be responsible for their own health” (Laverack et al., 2009). HATs comprise community members that identify health priorities in their community, determine how they will be addressed, communicate with the local peak health authority (e.g.
Queensland Aboriginal and Islander Health Council and Queensland Health) and monitor service delivery in the community (Gauld et al., 2011). While evidence is still sparse, existing research suggests that this collective community governance approach to health service delivery represents a positive move towards building capacity in remote communities and “closing the gap in health outcomes between Indigenous and non-Indigenous communities” (Coombe et al., 2008, p 611).
NT Australian Better Health Initiative (ABHI) project
Funded through COAG, the ABHI to improve health service integration has been implemented in the Northern Territory (2008-2010) and has shown promising outcomes. The project involved a
partnership between the Commonwealth Department of Health and Ageing, Department of Health and Families, General Practice Network NT, AMSANT, Healthy Living NT and NT Consumers (Race and Nash, 2010). Access to services for patients needing dialysis or those with end-stage renal disease is challenging and requires a number of issues to be considered, including housing, limited health literacy and English language skills, social and cultural dislocation, and costs of living away from home. Results from the evaluation study (Race and Nash, 2010) suggest that the ABHI project enabled development of business models for claiming relevant MBS items; helped to resolve IT
incompatibility problems (e.g. access to shared electronic health records); and facilitated partnerships between service providers.xv
As a result, patients undergoing renal dialysis in areas where ABHI was implemented were more likely to receive holistic health checks through team care (GP, nurse, Aboriginal health worker); and shared care referral pathways were established (e.g. podiatrists, psychologists, exercise
physiologists) as needed.
xv Further details on the evaluation study were not available.