ACHSE BroadcastACHSE Broadcast21 August 2002:21 August 2002:
Managing for Indigenous Managing for Indigenous health outcomeshealth outcomes
Robyn McDermottRobyn McDermott
Barbara SchmidtBarbara Schmidt
Terry MehanTerry Mehan
Things are changingThings are changing
• The global health transition and its determinants
• Consequences of epidemic chronic diseases
• The social gradient in risk behaviours and outcomes
• Implications for health services
25
50
%
Communicable diseases, maternal and perinatal
conditions and nutritional deficiencies
Injuries
DALYs, by broad cause group 1990 - 2020in Developing Countries (baseline scenario)
DALY = Disability adjusted life-year
1990
2020
Source: WHO, Evidence, Information and Policy, 2000
Noncommunicableconditions
• Coronary heart disease• Stroke• Diabetes Compl.• Peripheral vascular disease• Several cancers• COPD/emphysema
EndpointsEndpointsIntermediateRisk
Factors/Diseases
•HypertensionHypertension
•DiabetesDiabetes
•ObesityObesity
•Blood LipidsBlood Lipids
BehaviouralBehaviouralRisk FactorsRisk Factors• Tobacco• Nutrition • Alcohol• Physical Activity
BehaviouralBehaviouralRisk FactorsRisk Factors• Tobacco• Nutrition • Alcohol• Physical Activity
Risk Determinants•Age, Sex •Genes
Risk Determinants•Age, Sex •Genes
Socio-economic, Cultural & Environmental
Conditions
Socio-economic, Cultural & Environmental
Conditions
Noncommunicable Diseases: Risk Factors and Endpoints
Burden of disease attributable to the major Burden of disease attributable to the major risk factors in Australia, 1996risk factors in Australia, 1996
(% of total DALYs)(% of total DALYs)Source: Mathers et al. Bull WHO, 2001Source: Mathers et al. Bull WHO, 2001
0
2
4
6
8
10
12
Tob
acco
Phy
sica
lin
acti
vity
Hig
h B
P
Alc
ohol
harm
Obe
sity
Low
F&
V
MalesFemales
Smoking prevalence in Queensland in Smoking prevalence in Queensland in 1998 by SES1998 by SES
Source: Queensland Statewide Health Survey, 1998Source: Queensland Statewide Health Survey, 1998
0
5
1015
20
25
3035
40
45
50
High SES Middle SES Low SES Lowest SES
S e lf r e p o r te d to b a c c o s m o k in gA b o r ig in a l p a r t ic ip a n ts ,
W e ll P e r s o n ’s H e a lth C h e c k , 1 9 9 8 -2 0 0 0
0
10
20
30
40
50
60
70
80
15-24years
25-34Years
35-44years
45-54years
55+ years
FemalesMales
Rate ratios for lung cancerRate ratios for lung cancerRural, remote and Indigenous Rural, remote and Indigenous
communities, Queenslandcommunities, QueenslandSource: HIC Circular No. 54, Feb 2000Source: HIC Circular No. 54, Feb 2000
0
50
100
150
200
250
300
SIR 1982-96 SMR 1982-96
MaleFemale
Mortality inside and outside capital cities Mortality inside and outside capital cities in Australia, 1986 and 1996in Australia, 1986 and 1996All Causes, age standardised rates/100,000All Causes, age standardised rates/100,000
Source: Sexton et al, MJA 2000Source: Sexton et al, MJA 2000
0
100
200
300
400
500
600
700
800
1986 males
1996 males
1986females
1996females
Capital citiesOutside Capitals
CHD Mortality within and outside capital CHD Mortality within and outside capital cities in Australia, 1986 and 1996cities in Australia, 1986 and 1996
Age-standardised rates/100,000Age-standardised rates/100,000Source: Sexton et al, MJA 2000Source: Sexton et al, MJA 2000
0
50
100
150
200
250
1986 males
1996 males
1986females
1996females
Capital citiesOutside capital cities
Proportion of population in each SEIFA quintile,Proportion of population in each SEIFA quintile,Northern Zone and QueenslandNorthern Zone and Queensland
Source: 1996 CensusSource: 1996 Census
0
10
20
30
40
50
60
Q1 Q2 Q3 Q4 Q5
Non-Indigenous QLDNon-Indigenous NZIndigenous QLDIndigenous NZ
Food Availability- The Healthy Food Access Basket
study (May/Apr, 2000)
The HFAB study looked at market items in three baskets. These were:
• Fruit and Vegetables basket• Healthy Food Access Basket (pictured left)• Tobacco and Take-away basket
Basket Reference Cost % Cost %Fruit, Vegetables and Legumes in Basket
$106.22 $174.24 164% $162.76 153%
Healthy Food Access Basket
$291.41 $445.11 153% $432.53 148%
Tobacco & Take-away Basket
$23.29 $30.00 129% $27.87 120%
Torres RemoteCape York & Mt Isa Remote
Prevalence of diabetes, Indigenous NQ (WPHC) and Australia (AusDiab),
1999-2000
0
10
20
30
40
50
60
15-24 25-34 35-44 45-54 55-64 65+
Non-IndigenousAboriginalTorres Strait Islander
Determinants of incident Determinants of incident Type 2 diabetes in a populationType 2 diabetes in a population
• Overweight/obesity (central obesity)
• Birth weight/weight gain in young adulthood
• Physical inactivity
• Tobacco smoking
• Harmful/hazardous alcohol consumption
• Intra-uterine exposures (glycemia, chronic “stress”, tobacco, low micronutrient density)
• Chronic, systemic stress in the social environment
• Lifetime SES
Male
0
500
1000
1500
2000
2500
3000
3500
1993/94 1994/95 1995/96 1996/97 1997/98 1998/99
Rat
e (p
er 1
00 0
00)
Torres Strait & NPA HSD Qld
North West RA Cape York HSD
Diabetes mellitus- Hospital Separations
Female
0
500
1000
1500
2000
2500
3000
3500
1993/94 1994/95 1995/96 1996/97 1997/98 1998/99
Rat
e (p
er 1
00 0
00)
Torres Strait & NPA HSD Qld
North West RA Cape York HSD
The Chronic Disease Strategy
PREVENTION EARLY DETECTIONMANAGEMENTTobacco
smokingTobaccosmoking
Physical activity & nutrition
Physical activity & nutrition
Alcohol StrategyAlcohol Strategy
Healthy young women/babiesHealthy young women/babies
Safe SexSafe Sex
ImmunisationImmunisation
Mental HealthMental Health
Annual adult health check
Annual adult health check
Brief Interventions
Brief Interventions
Children’s health checks
Children’s health checks
Women’s health checks
Women’s health checks
Registers and recall systems, and standard treatment protocols for:
- Diabetes
- Cardiovascular disease
- Renal disease
- Chronic respiratory disease
- Sexually transmitted infections
- Mental Health
Registers and recall systems, and standard treatment protocols for:
- Diabetes
- Cardiovascular disease
- Renal disease
- Chronic respiratory disease
- Sexually transmitted infections
- Mental Health
Environmental Health
Environmental Health
How can we improve technical How can we improve technical efficiency in PHC level efficiency in PHC level
management of chronic diseasemanagement of chronic disease?•RegistersRegisters
•Recall systemsRecall systems
•Expert systems (Best practice, Expert systems (Best practice, “EBM”, skilled workforce)“EBM”, skilled workforce)
•Information systems (Wagner, 1996)Information systems (Wagner, 1996)
Prevention:Prevention: Whose job?Whose job?
• Health servicesHealth services• EducationEducation• Community Community
organisationsorganisations• Local governmentLocal government• TransportTransport• Food, tobacco, alcohol Food, tobacco, alcohol
industriesindustries• OthersOthers
ENHANCED MODEL OF ENHANCED MODEL OF PRIMARY HEALTH CAREPRIMARY HEALTH CARE
Focusing the work of primary health care in Indigenous
communities
Enhanced Model of Primary Health Care
Changing the way we do business
• Framework for enhancing services at community level
•Identifies the core activities of PHC in Indigenous Communities
Required inputsNecessary
supportsRequired
outcomes
Enhanced Model of Primary Health Care
INPUTS ACTIVITIES OUTPUTS
Health status Program
activity Community
identified needs
Enhanced Model of Primary Health Care
INFORMATION EXCHANGE
• Health Indicators
• Services currently provided
• Budget and revenue
• Community issues & needs identified through consultation
Enhanced Model of Primary Health Care
INPUTS ACTIVITIES OUTPUTS
Planning in partnership with community What is the burden of disease? What does the evidence say can be
done? Is what we are doing making a difference?
Health status Program
activity Community
identified needs
Shared
understanding of health needs
Enhanced Model of Primary Health Care
PARTNERSHIPS
EXAMPLES
All of Government
- Meeting Challenges Making Coices
Regional
- Draft MOU with Apunipima
Community
- Partnership agreement - Yarrabah
Enhanced Model of Primary Health Care
INPUTS ACTIVITIES OUTPUTS
Improved health
outcomes
Planning in partnership with community What is the burden of disease? What does the evidence say can be
done? Is what we are doing making a difference?
Evidence-based programs The chronic disease strategy Acute care services
Health status Program
activity Community
identified needs
Shared understanding
of health needs
Enhanced Model of Primary Health Care
EVIDENCE BASED PROGRAMS
STRATEGIES
• CHRONIC DISEASE STRATEGY
• PUBLIC HEALTH APPROACH
• COLLABORATIE PRACTICE MODEL
The Chronic Disease Strategy
PREVENTION EARLY DETECTIONMANAGEMENTTobaccosmokingTobaccosmoking
Physical activity & nutrition
Physical activity & nutritionAlcohol StrategyAlcohol Strategy
Healthy young
women/babies
Healthy young
women/babiesSafe SexSafe Sex
ImmunisationImmunisation
Mental HealthMental Health
Annual adult health
check
Annual adult health
check
Brief Intervention
s
Brief Intervention
s
Children’s health checks
Children’s health checks
Women’s health checks
Women’s health checks
Registers and recall systems, and standard treatment protocols for:
- Diabetes
- Cardiovascular disease
- Renal disease
- Chronic respiratory disease
- Sexually transmitted infections
- Mental Health
Registers and recall systems, and standard treatment protocols for:
- Diabetes
- Cardiovascular disease
- Renal disease
- Chronic respiratory disease
- Sexually transmitted infections
- Mental Health
Environmental Health
Environmental Health
Enhanced Model of Primary Health Care
INPUTS ACTIVITIES OUTPUTS
Required Supports Information systems (Ferret) Leadership (management, clinical,
professional) Workforce with the correct skills mix
Improved health
outcomes
Planning in partnership with community What is the burden of disease? What does the evidence say can be
done? Is what we are doing making a difference?
Evidence-based programs The chronic disease strategy Acute care services
Quality standards
Health status Program
activity Community
identified needs
Shared
understanding of health needs
Enhanced Model of Primary Health Care
REQUIRED SUPPORT INFORMATION SYSTEMS
Primary Care Information Systems (Better Health Outcomes Project)
WORKFORCE
Workforce plan developed to:
- Shape the future workforce
- Increase indigenous employment
Innovative workforce strategies to improve recruitment and retentions of all staff
Enhanced Model of Primary Health Care
INPUTS ACTIVITIES OUTPUTS
Required Supports Information systems (Ferret) Leadership (management, clinical,
professional) Workforce with the correct skills mix
Improved health
outcomes
Planning in partnership with community What is the burden of disease? What does the evidence say can be
done? Is what we are doing making a difference?
Evidence-based programs The chronic disease strategy Acute care services
Quality standards
Health status Program
activity Community
identified needs
Shared
understanding of health needs
Quality approaches to health care delivery Protocols and care pathways in primary
health care centres Recall and patient management systems
Increased Indigenous employment
Enhanced Model of Primary Health Care
QUALITY APPROACHES
PRIMARY CLINICAL CARE MANUAL
CHRONIC DISEASE MANAGEMENT PROTOCOLS
STANDARD HRM PRACTICES
DEVELOPMENT OF QUALITY STANDARDS FOR PRIMARY HEALTH CARE CENTRES
Enhanced Model of Primary Health Care
INPUTS ACTIVITIES OUTPUTS
Required Supports Information systems (Ferret) Leadership (management, clinical,
professional) Workforce with the correct skills mix
Improved health
outcomes
Planning in partnership with community What is the burden of disease? What does the evidence say can be
done? Is what we are doing making a difference?
Evidence-based programs The chronic disease strategy Acute care services
Quality standards
Health status Program
activity Community
identified needs
Shared
understanding of health needs
Quality approaches to health care delivery Protocols and care pathways in primary
health care centres Recall and patient management systems
Training Recruitment Workforce Management Indigenous workforce development
Increased Indigenous employment
Sustainable quality
workforce
KEY CHALLENGESKEY CHALLENGESCHANGE MANAGEMENT
• Culture of health service providers and the community• Aligning the organisation to business objectivesZonal•Clearing House for Indigenous Rural and Remote ProjectsDistrict•Changing organisational structures to increase the focus and management of primary health care services
COMMUNICATION• Communication plan
CHANGE MANAGEMENTCHANGE MANAGEMENT
CHANGE MANAGEMENT CHANGE MANAGEMENT
WHY CHANGE
•Health differentials are unacceptable
•Evidence suggests there is a better way
CHANGE MANAGEMENT CHANGE MANAGEMENT
COMPETENCIES FOR MANAGING CHANGE
•Technical apects
•People apsects
CHANGE MANAGEMENT CHANGE MANAGEMENT
TECHNICAL
•Evidenced based Programs
•Information systems•Right workforce mix
PEOPLE
•Ownership•Responsibility
•Shared understanding•Leadership
•Right workforce mix•Increased Indigenous
employment
SUSTAINABLE SOLUTIONS SUSTAINABLE SOLUTIONS
REQUIRES
• Community to understand the problems, own the solutions and take responsibility for the solutions
• The solution to be defined in the community context and not the provider context.
• True partnerships to support capacity development.
The Chronic Disease Strategy
PREVENTION EARLY DETECTION MANAGEMENT
TobaccosmokingTobaccosmoking
Physical activity & nutrition
Physical activity & nutrition
Alcohol StrategyAlcohol Strategy
Healthy young women/babiesHealthy young women/babies
Safe SexSafe Sex
ImmunisationImmunisation
Mental HealthMental Health
Annual adult health check
Annual adult health check
Brief Interventions
Brief Interventions
Children’s health checks
Children’s health checks
Women’s health checks
Women’s health checks
Registers and recall systems, and standard treatment protocols for:
- Diabetes
- Cardiovascular disease
- Renal disease
- Chronic respiratory disease
- Sexually transmitted infections
- Mental Health
Registers and recall systems, and standard treatment protocols for:
- Diabetes
- Cardiovascular disease
- Renal disease
- Chronic respiratory disease
- Sexually transmitted infections
- Mental Health
Environmental Health
Environmental Health
THE WAY FORWARDTHE WAY FORWARD
•EMPHC and CDS deal with technical issues
•Need to get the people side right
Strategy implementation requires checklist oftechnical and people aspects to be addressed.
ACHSE BroadcastACHSE Broadcast21 August 2002:21 August 2002:
Managing for Indigenous Managing for Indigenous health outcomeshealth outcomes
Robyn McDermottRobyn McDermott
Barbara SchmidtBarbara Schmidt
Terry MehanTerry Mehan