building the evidence for service and workforce reform – a case study institute for urban...

Building the evidence for service and workforce reform – a case study

Institute for Urban Indigenous Health

Health Workforce Australia Conference Adelaide Nov 2013

Source: Population Division of DESA UN Secretariat: World Population Prospects: the 2008 Revision Population Database www.un.org

Life expectancy at birth in selected countries

* External causes include intentional self-harm, accidents, assaults, poisoning

Causes of excess mortality

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

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

No. of completed health assessments

2008-09

• 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 socio-economic 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

What was the evidence in SEQ?

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.

Our Vision

• 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

Institute for Urban Indigenous 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





Suburbs in catchment

Indigenous population

Active AMS Clients

% of population

Target population = 50% catchment

New clients needed to reach target*

1603 229 14% 802 573807 147 18% 404 257371 226 61% 186 0589 324 55% 295 0

2536 1211 48% 1674 463

728 79 11% 364 285

25 2 8% 13 1157 1 2% 29 2870 9 13% 35 26

322 25 8% 161 13667 11 16% 34 23

47 2 4% 24 22

Indigenous Population by Suburb/Division of General Practice

0 to 1010 to 2525 to 5050 to 100

100 to 200200 to 500500 to 3,500

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

we need the organised approach - not the ‘organ’ approach”

The organised approach…

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 $/itemTotal $/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

Other consultations

short 4 $ 35.60 $ 142.40

medium 12 $ 69.00 $ 828.00

long 1 $ 101.50 $ 101.50

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) 1600 6 $ 51.95 $ 311.70 AHW F/U GPMP/TCA (10950) 240 1 $ 51.95 $ 51.95

10990 (50% cons) 14 $ 5.90 $ 82.60

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




• How much?




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




• How much?




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

PodiatryPolitical Science

Business and

Economics

Social Work

Counselling Arts Biomedic

al 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 4 weeks F/T starting 22/7

Audit of Webster pack ordering – process and protocol - Kambu

Health Science One day/week for 11 weeks starting 22/7

B.u.bs Club – developing a teddy-bears picnic and calendar of developmental milestones

Health Science One day/week for 11 weeks starting 22/7

Tobacco cessation program evaluation

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)


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


Developing a group literacy program with SLP students



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 follow-up plan for participants of the Warriors program

Psychology 3 days/week starting 22/7

Parenting programs evaluation and development of a framework




• How much?




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

1 2 3 4 5 6 7 8 9 10 11 120%

20%

40%

60%

80%

100%

120%

140%

160%

180%Health Assessments - % of TIP targets reached by clinic

DM care plan 99

No DM care plan PLUS BSL > 11 or HbA1C >6.6% 34

Asthma or chronic respiratory care plan 74No asthma or CR care plan PLUS on bronchodilator or preventive puffer medication 67

Coronary artery disease care plan 13No CAD care plan PLUS on antianginal, b-blocker or anti-coag medication 36

DIABETES

RESPIRATORY DISEASE

CARDIOVASCULAR DISEASE

KIDNEY DISEASE

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

71%65%

% Aboriginal and Torres Strait Islander clients up to date with health assessment (715)

Male

Female

Male Female0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Active 16-29 year old Aboriginal and Torres Strait Islander clients with chlamydia screen in the last 12m

BP last 6m

Last BP systolic <130

Last BP diastolic <80

HbA1C last 6m

HbA1C <7.5%

HbA1C >10%

TC last 12m

Last TC <4

BMI last 6m

BMI norm

al

BMI overw

eight

BMI obese

ACR last 12m

Smoking status assessed

-30%

-20%

-10%

0%

10%

20%

30%

40%

50%

60%

Cohort of clients with diabetes: % change in selected measures from year 1 to year 2 (n=35)

building the evidence for service and workforce reform – a case study institute for urban...

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