Building the evidence for service and workforce
reform – a case study
Institute for Urban Indigenous Health
Health Workforce Australia Conference Adelaide Nov 2013
Life expectancy at birth in selected countries
Source: Population Division of DESA UN Secretariat: World Population Prospects: the 2008 Revision Population
Database www.un.org
Causes of excess mortality
* External causes include intentional self-harm, accidents, assaults, poisoning
Burden of disease – Disability Adjusted Life Years (DALYs)
Vos T, Barker B, Stanley L, Lopez AD 2007. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003.
Brisbane: School of Population Health, The University of Queensland.
% Indigenous Health Gap (DALYs) by selected causes – by remoteness
Vos T, Barker B, Stanley L, Lopez AD 2007. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003.
Brisbane: School of Population Health, The University of Queensland.
Maternal and neonatal outcomes for an urban Indigenous population
compared with their non-Indigenous counterparts
Sue Kildea, Helen Stapleton, Rebecca Murphy, Machellee Kosiak and Kristen Gibbons. BMC Pregnancy
and Childbirth 2013, 13:167 doi:10.1186/1471-2393-13-167
Projected Indigenous population 2006 - 2031
Nicholas Biddle: CAEPR Indigenous Population Project 2011 Census Papers No. 14/2013 – Population
Projections. http//caepr.anu.edu.au/publications/censuspapers.php
Nicholas Biddle: CAEPR Indigenous Population Project 2011 Census Papers No. 14/2013 – Population
Projections. http//caepr.anu.edu.au/publications/censuspapers.php
No. of completed health assessments 2008-09
General Practice
Network
No of 708 checks % of eligible
children
screened
No of 710 checks % of eligible
adults screened
South East
Alliance
59
3.4
126
4.5
Brisbane South
195
12.3
452
17.3
Gold Coast
35
1.5
28
2
Logan Network
42
1.1
67
2.2
Ipswich
74
2
52
2
Moreton Bay
0
0
14
0.6
GP Partners
27
3
35
0.8
Total
432
3
774
4.1
What was the evidence in SEQ?
• Limited reliable evidence available on the specific needs of urban
Aboriginal and Torres Strait Islander people in SEQ
• Approximately 20-25% of the Aboriginal and Torres Strait Islander
population were accessing ATSICCHS clinics; limited evidence available
suggested mainstream was not well equipped to be able to respond
• Focus of Indigenous specific COAG investment by Government on remote
communities; focus in urban and regional areas centred on enhancing
access to mainstream services
• Continued growth and dispersal of Indigenous population with ‘shift’ to
outer-urban areas – concentration of populations in areas of low socioeconomic areas, distant from where ATSICCCHS clinics were originally
located
• Competing interests - including efforts to secure new resources – amongst
ATSICCHS located within the SEQ region
• Uncertainty regarding continued grant funding, with mounting imperative
to reduce reliance on grant funding and to increase long-term economic
viability of ATSICCHS
• Complexities of coordinating care across range of different health and
related service providers
Our Vision
The vision of the IUIH is to achieve equitable health outcomes for urban
Aboriginal and Torres Strait Islander peoples and to ensure that all Aboriginal
and Torres Strait Islander people in the south east Queensland region have access
to culturally safe and comprehensive primary health care.
Institute for Urban Indigenous Health
• Established as public company limited by guarantee
• Mixed-Board structure, with:
• 1 representative from each member ACCHS:
• ATSICHS Brisbane
• Kambu Medical Centre
• Yulu-Burri-Ba Health Service
• Kalwun Health Service
PLUS
• 4 directors appointed for specific skills:
• Social Marketing/Community Engagement
• Research /Teaching
• Finance/Business/Governance
• Clinical/Public Health
The IUIH aims to increase health service access and opportunities
through provision of support for Aboriginal and Torres Strait Islander
health service development and coordination across the SEQ region.
The IUIH also aims to support the effective implementation of the COAG
‘Close the Gap’ initiatives and other strategic developments in the region
with emphasis on promoting partnerships and integration with other
mainstream health services.
Responding to the evidence – system and service reform
•
Identify and prioritise areas of SEQ for new ATSICCHS clinics
establishment
•
Coordinate a strategic regional approach to community engagement,
health promotion and service access
•
Redesign health service systems to improve efficiency and quality, and to
increase generation of MBS income
•
On behalf of member ATSICCHS, forge partnerships with mainstream
agencies and providers to enhance the response to the needs of Aboriginal
and Torres Strait Islander people in SEQ
•
Develop a coordinated regional response to the development of a sustainable
Indigenous health workforce
From evidence to system reform…
•
Identify and prioritise areas of SEQ for new ATSICCHS clinics
development
•
Coordinate a strategic regional approach to community engagement,
health promotion and service access
•
Redesign health service systems to improve efficiency and quality, and to
increase generation of MBS income
•
On behalf of member ATSICCHS, forge partnerships with mainstream
agencies and providers to enhance the response to the needs of Aboriginal
and Torres Strait Islander people in SEQ
•
Develop a coordinated regional response to the development of a sustainable
Indigenous health workforce
Suburbs in catchment
Indigenous
population
Active
AMS
Clients
Target
% of
population =
population 50% catchment
New clients
needed to
reach target*
1603
807
371
589
2536
229
147
226
324
1211
14%
18%
61%
55%
48%
802
404
186
295
1674
573
257
0
0
463
728
79
11%
364
285
25
57
70
322
67
2
1
9
25
11
8%
2%
13%
8%
16%
13
29
35
161
34
11
28
26
136
23
47
2
4%
24
22
Indigenous Population by Suburb/Division of General Practice
0 to
10
10 to
25
25 to
50
50 to 100
100 to 200
200 to 500
500 to 3,500
From evidence to system reform…
•
Identify and prioritise areas of SEQ for new ATSICCHS clinics
development
•
Coordinate a strategic regional approach to community engagement,
health promotion and service access
•
Redesign health service systems to improve efficiency and quality, and to
increase generation of MBS income
•
On behalf of member ATSICCHS, forge partnerships with mainstream
agencies and providers to enhance the response to the needs of Aboriginal
and Torres Strait Islander people in SEQ
•
Develop a coordinated regional response to the development of a sustainable
Indigenous health workforce
Community engagement, health promotion & service access
•
•
•
•
•
Deadly Choices program
Marketing
Community Days
Incentives – Deadly Choices shirts, competitions, etc.
Targeted, localised engagement strategy linking back to clinics –
Community Liaison Officers
From evidence to system reform…
•
Identify and prioritise areas of SEQ for new ATSICCHS clinics
development
•
Coordinate a strategic regional approach to community engagement,
health promotion and service access
•
Redesign health service systems to improve efficiency and quality, and
to increase generation of MBS income
•
On behalf of member ATSICCHS, forge partnerships with mainstream
agencies and providers to enhance the response to the needs of Aboriginal
and Torres Strait Islander people in SEQ
•
Develop a coordinated regional response to the development of a sustainable
Indigenous health workforce
The organised approach…
we need the organised
approach - not the
‘organ’ approach”
From evidence to system reform…
•
Identify and prioritise areas of SEQ for new ATSICCHS clinics
development
•
Coordinate a strategic regional approach to community engagement,
health promotion and service access
•
Redesign health service systems to improve efficiency and quality, and to
increase generation of MBS income
•
On behalf of member ATSICCHS, forge partnerships with mainstream
agencies and providers to enhance the response to the needs of
Aboriginal and Torres Strait Islander people in SEQ
•
Develop a coordinated regional response to the development of a sustainable
Indigenous health workforce
From evidence to system reform…
•
Identify and prioritise areas of SEQ for new ATSICCHS clinics
development
•
Coordinate a strategic regional approach to community engagement,
health promotion and service access
•
Redesign health service systems to improve efficiency and quality, and to
increase generation of MBS income
•
On behalf of member ATSICCHS, forge partnerships with mainstream
agencies and providers to enhance the response to the needs of Aboriginal
and Torres Strait Islander people in SEQ
•
Develop a coordinated regional response to the development of a
sustainable Indigenous health workforce
Develop a coordinated regional response to the development of a
sustainable Indigenous health workforce
1. What workforce do we need to meet demand in SEQ?
•
What type / composition?
•
How much?
2. How do we develop the skills and capacity of the existing workforce to do
the job?
3. How do we successfully expand the workforce to keep up with future
growth and demand?
4. How do we specifically enhance Aboriginal and Torres Strait Islander
employment and career development?
Develop a coordinated regional response to the development of a
sustainable Indigenous health workforce
1. What workforce do we need to meet demand in SEQ?
•
What type / composition?
•
How much?
2. How do we develop the skills and capacity of the existing workforce to do
the job?
3. How do we successfully expand the workforce to keep up with future
growth and demand?
4. How do we specifically enhance Aboriginal and Torres Strait Islander
employment and career development?
If the full “cycle of care” is completed for everyone who’s eligible, what
does a daily workload look like?
Assumptions and calculations:
•
1 GP per 1000 regular Aboriginal and Torres Strait Islander clients…
•
a full cycle of care is completed for all regular clients of the service over a 12
month period
•
At least 30% of total regular client population will be eligible and benefit from a
GPMP /TCA (this is conservative)
•
50% of nurse follow up visits after 715 and 100% nurse follow up visits after
GPMP/TCA are captured in a 12 month cycle
•
2 AHW allied health items after a 715 and 1 of these items after a GPMP /TCA is
claimed in a 12 month cycle
•
Remaining GP time in the day is taken up with mostly mid-range consultations –
around 20 mins duration
Year
Day
$/item
Total $/day
GP Contacts
715 (100%)
800
3
$ 204.20
$
612.60
GPMP (30%)
240
1
$ 138.75
$
138.75
TCA (30%)
240
1
$ 109.95
$
109.95
GPMP / TCA RV (3/y)
720
3
$ 138.70
$
416.10
4
$ 35.60
$
142.40
12
$ 69.00
$
828.00
1
$ 101.50
$
101.50
Other consultations
short
medium
long
Non-GP contacts
RN 715
800
3
RN GPMP/TCA
240
1
RN F/U 715 (10987)
4000
16
$ 23.55
$
376.80
RN F/U GPMP/TCA (10997)
1200
5
$ 11.80
$
59.00
AHW F/U 715 (81300)
AHW F/U GPMP/TCA
(10950)
1600
6
$ 51.95
$
311.70
240
1
$ 51.95
$
51.95
$
$
82.60
10990 (50% cons)
14
5.90
1x GP
1x Practice Manager
1 x Community Liaison Officer
1 x Driver
1.5 - 2 x Receptionists
1 x Aboriginal Health Worker
1 x Clinic Nurse
1 x Chronic Disease Nurse
Key principles
1. Everyone is critical, no-one is spare and everyone will be missed if they’re
absent – so also need multi-skilled workforce
2. Everyone is used to their license
3. Health professionals other than GPs not only to support effective
engagement, access and care, but also make a significant (around 25%)
contribution to generation of MBS revenue through interactions NOT
involving contact with GP
4. Size matters – in this model, begin to lose efficiency once service grows
beyond a 2 GP core
Develop a coordinated regional response to the development of a
sustainable Indigenous health workforce
1. What workforce do we need to meet demand in SEQ?
•
What type / composition?
•
How much?
2. How do we develop the skills and capacity of the existing workforce to do
the job?
3. How do we successfully expand the workforce to keep up with future
growth and demand?
4. How do we specifically enhance Aboriginal and Torres Strait Islander
employment and career development?
1. Mapped functions to job roles  development of standardised regional
position descriptions, avoiding duplication and ensuring all key functions
are covered
2. Focus on skills not qualifications
3. Training needs – individual assessment and development of training plan
4. Partnership with training institutions to secure access to industry-specific
training for SEQ ATSICCHS workforce
5. On-the-job training – emphasis on skills transfer (formalised in PDs),
mentorship and supervision, interdisciplinary learning
6. Developing Proper Partnerships – cultural mentor program
Develop a coordinated regional response to the development of a
sustainable Indigenous health workforce
1. What workforce do we need to meet demand in SEQ?
•
What type / composition?
•
How much?
2. How do we develop the skills and capacity of the existing workforce to do
the job?
3. How do we successfully expand the workforce to keep up with future
growth and demand?
4. How do we specifically enhance Aboriginal and Torres Strait Islander
employment and career development?
A home grown workforce
• Funding and support from GPET / RTPs to support postgraduate medical
training – 0.5 medical educator  expanded GPR placements from 1
historically to 7 in 2013
• Funding from UQ for a full-time position to support effective undergraduate
student placements
 Regional capacity to enhance both volume and quality of training experience
for both trainees and services
Semester 1 2013
Medicine
Occupational
Therapy
Dentistry and
Oral health
Speech
Pathology
Human
Movement
Studies
Optometry
Psychology
Nursing and
Midwifery
Pharmacy
Podiatry
Political
Science
Business and
Economics
Social Work
Counselling
Arts
Biomedical
Science
Discipline
Type of Placement
Project
Pharmacy
4 weeks F/T starting 22/7
Developing links with local pharmacies – improving pharmacy education for
Work It Out sessions
Pharmacy
Health Science
4 weeks F/T starting 22/7
One day/week for 11
weeks starting 22/7
Health Science
One day/week for 11
weeks starting 22/7
Health Science
4 days/ week for 10 weeks
starting 22/7
Work it Out – assisting with organising, administering, collecting and analysing
data from pre and post assessments for Work it Out Clients (could include one
day/week at Murri school sorting follow up from health check days)
Occupational Therapy
1 day/week for 11 weeks
starting 29/7
Embedding parent activities alongside Tumbletime, tools for school, Tumble-tots
programs to further engage parents and to model strategies that can be used at
home to expand and extend the children’s learning and skill development.
Occupational Therapy
and Speech Therapy
1 day/week for 11 weeks
starting 29/7
Developing a group literacy program with SLP students
Occupational Therapy
1 day/week for 11 weeks
starting 29/7
Development of an innovation showcase for SE Qld CCHS’s
Political Science
One day/week for 11
weeks starting 22/7
Developing a legal and ethical framework for shared electronic health records in
South-East Qld CCHS’s
Political Science
One day/week for 11
weeks starting 22/7
Warriors: Developing and implementing an evaluation framework and followup plan for participants of the Warriors program
Psychology
3 days/week starting 22/7
Audit of Webster pack ordering – process and protocol - Kambu
B.u.bs Club – developing a teddy-bears picnic and calendar of developmental
milestones
Tobacco cessation program evaluation
Parenting programs evaluation and development of a framework
Develop a coordinated regional response to the development of a
sustainable Indigenous health workforce
1. What workforce do we need to meet demand in SEQ?
•
What type / composition?
•
How much?
2. How do we develop the skills and capacity of the existing workforce to do
the job?
3. How do we successfully expand the workforce to keep up with future
growth and demand?
4. How do we specifically enhance Aboriginal and Torres Strait Islander
employment and career development?
Supporting Aboriginal and Torres Strait Islander training,
employment and career development
• ‘Pipeline” beginning with schools-based traineeships – e.g. in 2013, cert
II and Cert III allied health assistant training
• Cadetships; scholarships – service-funded as well as coordination of
funding from other sources
• Indigenous Youth Sports Program (IYSP)
• Mentor program – 2 way learning
• Critical mass
In addition to Aboriginal and Torres Strait Islander managers, ATSIHWs
and nurses, now also exercise physiologist, speech therapist, oral health
therapist, dental assistants, researchers including 2 PhD students, etc.
Managing system reform and improvement
Strong leadership
Simultaneous governance reform
Role of the IUIH “Spearhead”
Clinical governance framework
Continuous quality improvement:
• Research and evaluation
• Closing the data loop – monthly CQI meetings, regional
Lead Clinician Group meetings
• Motivating change – Team Incentive Plan; Leagues Table
Health Assessments
GPMPs
Health Assessments - % of TIP targets reached by clinic
180%
160%
140%
120%
100%
80%
60%
40%
20%
0%
1
2
3
4
5
6
7
8
9
10
11
12
DIABETES
DM care plan
99
No DM care plan PLUS BSL > 11 or HbA1C >6.6%
34
RESPIRATORY DISEASE
Asthma or chronic respiratory care plan
No asthma or CR care plan PLUS on bronchodilator
or preventive puffer medication
74
67
CARDIOVASCULAR DISEASE
Coronary artery disease care plan
No CAD care plan PLUS on antianginal, b-blocker or
anti-coag medication
13
36
KIDNEY DISEASE
Any CKD or ESKD care plan
10
No CKD care plan PLUS eGFR <60 or creatinine <120
17
Proteinuria Care Plan
13
No proteinuria care plan PLUS ACR > 10
22
Collaboration and coordination – a case example
Signing of statement of intent – IUIH / Brisbane ATSICHS / MNBML / Metro north HHS
3 new clinics in the last 2 years in Moreton Bay region (8500 population) – already
reaching around 3500 clients
Workforce – over 80% all staff are Aboriginal and Torres Strait Islander; 2 GPRs; 2
Aboriginal RN trainees; 2 AHW trainees
On target with Team Incentive Plan; early measures of clinical performance promising;
cost-benefit analysis underway (IUIH-contracted health economist)
Subcontracted by MNBML to run CTG program; contracted by MNHHS to deliver Care
Connect
Oral Health Service:
•
Fixed chair in Deception Bay clinic funded as part of capital establishment (QH)
•
Mobile Van funded by DOHA
•
Dentist and dental assistant – start up funding through Medicare Local (MNBML)
•
Funding from QH for Oral Health Therapist (new Aboriginal graduate with initial
supervision from QH OHT undertaking research project)
•
Ongoing operation – Medicare revenue generated through PHC service; vouchers from
QH for clients on wait list >5 years, Teen Dental funding
% Aboriginal and Torres Strait Islander clients up to
date with health assessment (715)
Male
65%
71%
Female
Active 16-29 year old Aboriginal and Torres Strait Islander
clients with chlamydia screen in the last 12m
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Male
Female
Cohort of clients with diabetes:
% change in selected measures from year 1 to year 2 (n=35)
60%
50%
40%
30%
20%
10%
0%
Smoking status assessed
ACR last 12m
BMI obese
BMI overweight
BMI normal
BMI last 6m
Last TC <4
TC last 12m
HbA1C >10%
HbA1C <7.5%
HbA1C last 6m
Last BP diastolic <80
-30%
Last BP systolic <130
-20%
BP last 6m
-10%