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Sentinel Sites Evaluation, Final Report

Sentinel Sites Evaluation Final Report – February 2013

Sentinel Sites Evaluation

Final Report

February 2013

Online ISBN: 978-1-74186-059-7

Publications Approval Number: 10490

Paper-based publications

© Commonwealth of Australia 2013

This work is copyright. You may reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health, GPO Box 9848, Canberra ACT 2601, or via e-mail to [email protected].

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© Commonwealth of Australia 2013

This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health, GPO Box 9848, Canberra ACT 2601, or via e-mail to [email protected].

This report has been independently prepared for the Australian Government Department of Health by Menzies School of Health Research and does not necessarily represent the views of the Australian Government

Contents

Definitions5

Guide to reading this report7

1.Executive summary9

1.1.Introduction9

1.2.Evaluation process and methods10

1.3.Overview of findings10

1.4.Effective implementation of the ICDP as a whole 16

1.5.Conclusion18

2.Introduction and methodology19

2.1.Introduction19

2.2.Overview of the Sentinel Sites21

2.3.Methodology23

2.4.Overview of Sentinel Sites31

3.National action to reduce Indigenous smoking rates (Measure A1) and helping Indigenous people reduce their risk of chronic disease (Measure A2)34

3.1.Description of measures34

3.2.State of implementation – national context36

3.3.Findings from Sentinel Sites41

3.4.Summary and conclusions71

3.5.Policy considerations77

4.Local Indigenous community campaigns to promote better health (Measure A3)79

4.1.Description of measure79


4.3.Findings from the Sentinel Sites84



5.Subsidising PBS medicine Co-payment (Measure B1)100






6.Higher Utilisation costs for MBS and PBS (Measure B2)158


6.2.Data sources and analysis161




7.Supporting primary care providers to coordinate chronic disease management (Measure B3 part A)218






8.Supporting primary care providers to coordinate chronic disease management (Measure B3 part B)307






9.Helping Indigenous people self-manage their risk of chronic disease (Measure B4)345






10.Increasing access to specialists and multidisciplinary team care (Measure B5 part A)365






11.Increasing access to specialists and multidisciplinary team care (Measure B5 part B)394






12.Workforce support, education and training (Measure C1)429



12.3.Findings from Sentinel Sites – orientation and Outreach Worker individualised training434

12.4.Findings from Sentinel Sites – training opportunities in AHSs for GPs and nurses446



13.Expanding the outreach and service capacity of Indigenous Health Services (Measure C2)467






14.Engaging Divisions of General Practice to improve Indigenous access to mainstream primary care (Measure C3)500






15.Attracting more people to work in Indigenous Health (Measure C4)544


15.2.State of Implementation – national context544

16.Clinical practice and decision support guidelines (Measure C5)546



17.Whole of ICDP548

17.1.Introduction548

17.2.Effective implementation of the whole of ICDP550



Figures

Figure 2.1: Location of Sentinel Sites21

Figure 2.2: Sentinel Sites evaluation processes24

Figure 3.1: Number of prescriptions for nicotine replacement therapy per 1000 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia by quarter, September 2010 – May 201258

Figure 3.2: Number of prescriptions for nicotine replacement therapy per 1000 Aboriginal and Torres Strait Islander people aged ≥15 years by remoteness of Sentinel Sites and the rest of Australia and quarter, September 2010 – May 201258

Figure 3.3: Number of prescriptions for nicotine replacement therapy per 1000 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia by quarter and age, September 2010 – May 201259

Figure 3.4: Enablers and constraints to effective implementation of the National Action to Reduce Aboriginal and Torres Strait Islander Smoking Rates and Helping Indigenous People Reduce their Risk of Chronic Disease measures65

Figure 3.5: Enablers and constraints to achievement of dedicated workforce with team structures and strategic focus66

Figure 3.6: Enablers and constraints to achievement of organisational environment with values and capacity to provide support68

Figure 3.7: Enablers and constraints to achievement of capability of the new health promotion workforce69

Figure 3.8: Enablers and constraints to achievement of health promotion capacity of the general primary health care workforce70

Figure 3.9: Enablers and constraints to achievement of complementary linkages with ICDP funded and other activities and services71

Figure 4.1: Enablers and constraints to effective implementation of the Local Indigenous Community Campaigns to Promote Better Health measure94

Figure 4.2: Enablers and constraints to achievement of an organisational environment with capacity to support evidence-based, locally generated initiatives95

Figure 4.3: Enablers and constraints to achievement of linkages with community, local service providers, and complementary linkages with other ICDP funded activities96

Figure 5.1: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia by quarter, September 2010 – May 2012111

Figure 5.2: Clinicians’ and practice managers’ responses to the statement ‘The PBS Co-payment measure has caused a large administration burden’ (% who strongly or partly agreed)112

Figure 5.3: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia, by rurality, quarter, September 2010 – May 2012114

Figure 5.4: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for urban Sentinel Sites and the rest of urban Australia, by site and quarter, September 2010 – May 2012115

Figure 5.5: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for case study regional Sentinel Sites and the rest of regional Australia, by site and quarter, September 2010 – May 2012116

Figure 5.6: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for enhanced tracking regional Sentinel Sites and the rest of regional Australia, by site and quarter, September 2010 – May 2012117

Figure 5.7: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for tracking Sentinel Sites and the rest of regional Australia, by site and quarter, September 2010 – May 2012118

Figure 5.8: PBS medicines supplied through S100 supply arrangements per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for remote Sentinel Sites, by site and quarter, March 2009 – May 2012119

Figure 5.9: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for remote Sentinel Sites and the rest of remote Australia, by site and quarter, September 2010 – May 2012120

Figure 5.10: PBS Co-payment measure prescriptions per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites (SS) and the rest of Australia (RA), by Anatomical Therapeutic Chemical category (anti-psychotic, cardiac, diabetes and obstructive airway disease) and quarter, September 2010 – May 2012122

Figure 5.11: PBS Co-payment measure prescriptions per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites (SS) and the rest of Australia (RA), by Anatomical Therapeutic Chemical category (anti-bacterial for systemic use and others) and quarter, September 2010 – May 2012123

Figure 5.12: Percentage PBS Co-payment measure prescriptions dispensed for Aboriginal and Torres Strait Islander people aged ≥15 years by Anatomical Therapeutic Chemical category for Sentinel Sites (SS) and the rest of Australia (RA), September 2010 – May 2012124

Figure 5.13: Number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia, by quarter and age, September 2010 – May 2012128

Figure 5.14: PBS Co-payment medicines dispensed by patient category for Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia, September 2010 – May 2012130

Figure 5.15: Clinicians' and practice managers' responses to the statement 'Eligibility criteria for Aboriginal and Torres Strait Islanders to access the PBS Co-payment measure are workable in practice' (% who strongly or partly agreed)131

Figure 5.16: Clinicians' responses to the statements 'Medications are more accessible for Aboriginal and Torres Strait Islanders than they have been previously' and 'Medication adherence has improved because of the PBS Co-payment measure' (% who strongly or partly agreed)144

Figure 5.17: Enablers and constraints to effective implementation of the PBS Co-payment measure146

Figure 5.18: Enablers and constraints to achievement of program design functional at site level147

Figure 5.19: Enablers and constraints to achievement of engagement of GPs in intent of the measure149

Figure 5.20: Enablers and constraints to achievement of engagement of pharmacists in intent of the measure150

Figure 5.21: Enablers and constraints to achievement of complementary linkages with other ICDP funded activities151

Figure 6.1: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites and the rest of Australia, by quarter, March 2009 – May 2012163

Figure 6.2: Number of GPs who claimed an adult health assessment (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia, by quarter, March 2009 – May 2012165

Figure 6.3: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites and the rest of Australia, by age and quarter, March 2009 – May 2012166

Figure 6.4: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites and the rest of Australia, by gender and quarter, March 2009 – May 2012167

Figure 6.5 Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites and the rest of Australia, by quarter and rurality, March 2009 – May 2012169

Figure 6.6: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in urban Sentinel Sites and the rest of urban Australia, by site and quarter, March 2009 – May 2012170

Figure 6.7: Number of GPs who claimed an adult health assessment (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for urban Sentinel Sites, by quarter, March 2009 – May 2012171

Figure 6.8: Average number of adult health assessments (MBS items 704, 706, 710 and to 1 May 2010 thereafter 715) claimed per GP in urban Sentinel Sites, by quarter, March 2009 – May 2012171

Figure 6.9: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in case study regional Sentinel Sites and the rest of regional Australia, by site and quarter, March 2009 – May 2012173

Figure 6.10: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in enhanced tracking regional Sentinel Sites and the rest of regional Australia, by site and quarter, March 2009 – May 2012174

Figure 6.11: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in tracking regional Sentinel Sites and the rest of regional Australia, by site and quarter, March 2009 – May 2012174

Figure 6.12: Number of GPs who claimed an adult health assessment (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for case study regional Sentinel Sites, by quarter, March 2009 – May 2012175

Figure 6.13: Number of GPs who claimed an adult health assessment (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for enhanced tracking regional Sentinel Sites, by quarter, March 2009 – May 2012175

Figure 6.14: Number of GPs who claimed an adult health assessment (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for tracking regional Sentinel Sites, by quarter, March 2009 – May 2012176

Figure 6.15: Average number of adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per GP in case study regional Sentinel Sites, by quarter, March 2009 – May 2012176

Figure 6.16: Average number of adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per GP in enhanced tracking regional Sentinel Sites, by quarter, March 2009 – May 2012177

Figure 6.17: Average number of adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per GP in tracking regional Sentinel Sites, by quarter, March 2009 – May 2012177

Figure 6.18: Adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per 100 Aboriginal and Torres Strait Islander people aged ≥15 years in remote Sentinel Sites and the rest of remote Australia, by site and quarter, March 2009 – May 2012179

Figure 6.19: Number of GPs who claimed an adult health assessment (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for remote Sentinel Sites, by quarter, March 2009 – May 2012179

Figure 6.20: Average number of adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per GP in remote Sentinel Sites, by quarter, March 2009 – May 2012180

Figure 6.21: Follow-up services provided by a practice nurse or registered AHW per 100 Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS item 10987) for Sentinel Sites and the rest of Australia, by quarter, March 2009 – May 2012188

Figure 6.22: Follow-up services provided by a practice nurse or registered AHW per 100 Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS item 10987) for Sentinel Sites and the rest of Australia, by age and quarter, March 2009 – May 2012190

Figure 6.23: Follow-up services provided by a practice nurse or registered AHW per 100 Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS item 10987) for Sentinel Sites and the rest of Australia, by gender and quarter, March 2009 – May 2012190

Figure 6.24: Follow-up allied health services per 100 Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS items 81300–81360) for Sentinel Sites and the rest of Australia, by quarter, March 2009 – May 2012196

Figure 6.25: Follow-up allied health services per 100 Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS items 81300–81360) for Sentinel Sites and the rest of Australia, by age and quarter, March 2009 – May 2012197

Figure 6.26: Follow-up by allied health professionals per 100 Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS items 81300–81360) for Sentinel Sites and the rest of Australia, by gender and quarter, March 2009 – May 2012197

Figure 6.27: Enablers and constraints to effective implementation of adult health assessments and follow-up203

Figure 6.28: Enablers and constraints to achievement of changed norms about primary health care practice, and use of health assessments204

Figure 6.29: Enablers and constraints to achievement of a design functional at site level and aligns with improvements in care for Aboriginal and Torres Strait Islander people with or at risk of chronic conditions207

Figure 6.30: Enablers and constraints to achievement of service re-orientation from acute care to comprehensive and long-term approach to providing comprehensive primary health care for Aboriginal and Torres Strait Islander people208

Figure 6.31: Enablers and constraints to achievement of complementary linkages with other ICDP funded activities established211

Figure 7.1: Health Services that have received the PIP Indigenous Health Incentive sign-on payment (as a percentage of all PIP registered Health Services during the evaluation period) for Sentinel Sites and the rest of Australia, by sector and by quarter 2010–2012226

Figure 7.2: Number of Health Services receiving the PIP Indigenous Health Incentive sign-on payment per 1000 Aboriginal and Torres Strait Islander people aged ≥15 years in Sentinel Sites and the rest of Australia, by urban, regional and remote locations, May 2012229

Figure 7.3: Cumulative number of people registering for the PIP Indigenous Health Incentive per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia, by health sector, and quarter March 2010 – May 2012231

Figure 7.4: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012 by Sentinel Sites and the rest of Australia, by sector234

Figure 7.5: Clinicians' and practice managers' response to the statement 'Organising access for Aboriginal and Torres Strait Islander people to the PIP Indigenous Health Incentive has been easy' (% who strongly or partly agreed), by sector236

Figure 7.6: Clinicians' and practice managers' response to the statement 'The PIP Indigenous Health Incentive has caused a large administrative workload’ (% who responded ‘strongly agree’ or ‘partly agree’), by sector237

Figure 7.7: Patients registered (PIP Indigenous Health Incentive Patient Registration Payment) per 100 Aboriginal and Torres Strait Islander people for urban Sentinel Sites and the rest of urban Australia by sector, and quarter March 2010 – May 2012240

Figure 7.8: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012 by urban Sentinel Sites and the rest of urban Australia, by sector241

Figure 7.9: Patients registered (PIP Indigenous Health Incentive payment) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for urban Sentinel Sites and the rest of urban Australia and quarter, March 2010 – May 2012242

Figure 7.10: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012, by urban Sentinel Sites and rest of urban Australia243

Figure 7.11: Patients registered (PIP Indigenous Health Incentive Patient Registration Payment) per 100 Aboriginal and Torres Strait Islander people for regional Sentinel Sites and the rest of regional Australia by sector, and quarter, March 2010 – May 2012244

Figure 7.12: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012 by regional Sentinel Sites and the rest of regional Australia, by sector245

Figure 7.13: Patients registered (PIP Indigenous Health Incentive payment) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for case study regional Sentinel Sites and the rest of regional Australia by quarter, March 2010 – May 2012246

Figure 7.14: Patients registered (PIP Indigenous Health Incentive payment) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for enhanced tracking regional Sentinel Sites and the rest of regional Australia, by quarter, March 2010 – May 2012247

Figure 7.15: Patients registered (PIP Indigenous Health Incentive payment) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for tracking regional Sentinel Sites and the rest of regional Australia by quarter, March 2010 – May 2012247

Figure 7.16: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012, by case study regional Sentinel Sites and rest of regional Australia248

Figure 7.17: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012, by enhanced tracking regional Sentinel Sites and rest of regional Australia248

Figure 7.18: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012, by tracking regional Sentinel Sites and rest of regional Australia249

Figure 7.19: Patients registered (PIP Indigenous Health Incentive patient registration payment) per 100 Aboriginal and Torres Strait Islander people for remote Sentinel Sites and the rest of remote Australia by sector by quarter March 2010 – May 2012250

Figure 7.20: Percentage of PIP Indigenous Health Incentive registrants at the end of May 2012 who were also registered in the previous year, 2011 and 2012 by remote Sentinel Sites and the rest of remote Australia, by sector251

Figure 7.21: Patients registered (PIP Indigenous Health Incentive payment) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for remote Sentinel Sites and the rest of remote Australia by quarter, March 2010 – May 2012252

Figure 7.22: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive for Sentinel Sites and the rest of Australia, by sector and year 2010–2011253

Figure 7.23: Three quarter rolling averages for Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islanders aged ≥15 years for Sentinel Sites and the rest of Australia by sector, 2010–2012255

Figure 7.24: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for Sentinel Sites and the rest of Australia by sectors and year, 2010–2011256

Figure 7.25: Clinicians’ and practice managers’ responses to the statement: ‘Health Services have a clear understanding of what is required to receive tiered payments’ (% who strongly or partly agreed), by sector and report period259

Figure 7.26: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive for urban Sentinel Sites and the rest of urban Australia, by sector and year 2010–2011263

Figure 7.27: Three quarter rolling averages for Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people for urban Sentinel Sites and the rest of urban Australia by sector, 2010–2012264

Figure 7.28: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive for urban Sentinel Sites and the urban rest of Australia, by year 2010–2011265

Figure 7.29: Three quarter rolling averages for Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years, for urban Sentinel Sites and the rest of urban Australia, 2010–2012266

Figure 7.30: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for urban Sentinel Sites and the rest of urban Australia by sectors and year, 2010–2011267

Figure 7.31: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for urban Sentinel Sites and the rest of urban Australia by Sentinel Sites and year, 2010–2011267

Figure 7.32: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive for regional Sentinel Sites and the rest of regional Australia, by Sector and year 2010–2011268

Figure 7.33: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive in 2010 and 2011 for case study regional Sentinel Sites and the rest of regional Australia269

Figure 7.34: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive in 2010 and 2011 for enhanced tracking regional Sentinel Sites and the rest of regional Australia269

Figure 7.35: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive in 2010 and 2011 for tracking regional Sentinel Sites and the rest of regional Australia270

Figure 7.36: Three quarter rolling averages for Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people for regional Sentinel Sites and the rest of regional Australia, by sector, 2010–2012271

Figure 7.37: Three quarter rolling averages of Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for case study regional Sentinel Sites and the rest of regional Australia, 2010–2012272

Figure 7.38: Three quarter rolling averages of Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for enhanced tracking regional Sentinel Sites and the rest of regional Australia, 2010–2012272

Figure 7.39: Three quarter rolling averages of Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for tracking regional Sentinel Sites and the rest of regional Australia, 2010–2012273

Figure 7.40: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for regional Sentinel Sites and the rest of regional Australia by sectors and year, 2010–2011274

Figure 7.41: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for case study regional Sentinel Sites and the rest of regional Australia by Sentinel Sites and year, 2010–2011275

Figure 7.42: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for enhanced tracking regional Sentinel Sites and the rest of regional Australia by Sentinel Sites and year, 2010–2011275

Figure 7.43: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for tracking regional Sentinel Sites and the rest of regional Australia by Sentinel Sites and year 2010–2011276

Figure 7.44 Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive for remote Sentinel Sites and the rest of remote Australia, by sector and year 2010–2011277

Figure 7.45: Percentage of Tier 1 and Tier 2 payments for people registered for the PIP Indigenous Health Incentive in 2010 for remote Sentinel Sites and the rest of remote Australia278

Figure 7.46: Three quarter rolling averages for Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people for remote Sentinel Sites and the rest of remote Australia, by sector, 2010–2012279

Figure 7.47: Three quarter rolling averages of Tier 1 payments (PIP Indigenous Health Incentive) per 100 Aboriginal and Torres Strait Islander people aged ≥15 years for remote Sentinel Sites and the rest of remote Australia, 2010–2012280

Figure 7.48: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for remote Sentinel Sites and the rest of remote Australia by sectors and year, 2010–2011281

Figure 7.49: Tier 2 payments per 100 Aboriginal and Torres Strait Islander people for remote Sentinel Sites and the rest of remote Australia by Sentinel Sites and year, 2010–2011282

Figure 7.50: Enablers and constraints to effective implementation of the PIP Indigenous Health Incentive measure294

Figure 7.51: Enablers and constraints to achievement of incentive design functional at site level and aligns with improvements in care295

Figure 7.52: Enablers and constraints to achievement of incentivised care aligned with professional perspectives296

Figure 7.53: Enablers and constraints to achievement of implementation workable and practical at a site level298


Figure 8.1: Enablers and constraints to effective implementation of the Care Coordination and Supplementary Services measure332

Figure 8.2: Enablers and constraints to achievement of practical and workable program design that reaches areas of need333

Figure 8.3: Enablers and constraints to achievement of collaborative arrangements and service planning335

Figure 8.4: Enablers and constraints to achievement of Care Coordinators established in their role, with relevant referrals from GPs336

Figure 8.5: Enablers and constraints to achievement of supplementary services funding used to overcome barriers to care337


Figure 9.1: Enablers and constraints to effective implementation of initiatives Helping Indigenous People Self-manage their Risk of Chronic Disease356

Figure 9.2: Enablers and constraints to achievement of establishment of self-management as valid and worthwhile357

Figure 9.3: Enablers and constraints to achievement of improved knowledge and skills among relevant health care providers358

Figure 9.4: Enablers and constraints to achievement of re-orientation of care to build collaborative partnerships with patients359


Figure 10.1: Enablers and constraints to effective implementation of the Urban Specialist Outreach Assistance Program measure384

Figure 10.2: Enablers and constraints to achievement of practical and workable program design – through problem-solving and development of local solutions385

Figure 10.3: Enablers and constraints to achievement of established arrangements with host organisations and service providers and, where relevant, intermediary organisations386

Figure 10.4: Enablers and constraints to achievement of improved accessibility and appropriateness of specialist care387


Figure 11.1: Enablers and constraints to effective implementation of the Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease measure418

Figure 11.2: Enablers and constraints to achievement of program design practical and workable at local level418

Figure 11.3: Enablers and constraints to achievement of coordinated provision of services to meet local needs420

Figure 11.4: Enablers and constraints to achievement of access for patients and coordinated care421


Figure 12.1: Enablers and constraints to effective implementation of the orientation and individualised training for Outreach Workers measure452

Figure 12.2: Enablers and constraints to achievement of orientation and individualised training models that meet DGP and AHS service needs453

Figure 12.3: Enablers and constraints to achievement of OW role established in organisation454

Figure 12.4: Enablers and constraints to achievement of staff development linked to identified capacity gaps456


Figure 12.6: Enablers and constraints to effective implementation of the clinical training placements and scholarships measure459

Figure 12.7: Enablers and constraints to achievement of implementation practical for the AHS459

Figure 12.8: Enablers and constraints to achievement of measure aligns with core values of AHSs460


Figure 13.1: Trends in clinicians' and practice managers' responses to the statement 'The Outreach Worker is providing a service for the local Aboriginal and Torres Strait Islander people that was not previously available' (% who responded ‘strongly agree’ or ‘partly agree’), by sector480

Figure 13.2: Trends in clinicians' and practice managers' responses to the statement 'Local Aboriginal and Torres Strait Islander people are attending Health Services more regularly as a result of the work of the Outreach Worker' (% who responded ‘strongly agree’ or ‘partly agree’), by sector480

Figure 13.3: Enablers and constraints to effective implementation of the Expanding the Outreach and Service Capacity of Indigenous Health Services measure490

Figure 13.4: Enablers and constraints to achievement of population health orientation of the AHS491

Figure 13.5: Enablers and constraints to achievement of AHSs oriented to meeting community needs492

Figure 13.6: Enablers and constraints to achievement of linkages with local service providers and achievement of complementary linkages with other ICDP funded activities established493

Figure 14.1: Awareness of Indigenous Health Project Officer based at the Division of General Practice (% who responded ‘yes’) by sector511

Figure 14.2: Interviewees’ responses to the statement: ‘The IHPO has contributed to improved access to Health Services’ (% who responded ‘strongly agree’ or ‘partly agree’), overall and by evaluation cycle515

Figure 14.3: Number of patients on the clinical information system identified as Aboriginal and Torres Strait Islander by General Practice521

Figure 14.4: Interviewees’ responses to the statement: ‘The IHPO has contributed to improvements in Aboriginal and Torres Strait Islander identification at General Practice’ (% who responded ‘strongly agree’ or ‘partly agree’), overall and by evaluation cycle522

Figure 14.5: Interviewees’ responses to the statement: ‘The IHPO has been helpful in assisting to raise awareness of the new measures being implemented under the ICDP’ (% who responded ‘strongly agree’ or ‘partly agree’), overall and by evaluation cycle524

Figure 14.6: Interviewees’ responses to the statement: ‘The employment of IHPOs has helped to develop stronger links between primary health care services’ (% who responded ‘strongly agree’ or ‘partly agree’), overall and by report period527

Figure 14.7: Enablers and constraints to effective implementation of Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care measure532

Figure 14.8: Enablers and constraints to achievement of establishment of IHPO and OW in their role532

Figure 14.9: Enablers and constraints to achievement of change agents – ‘making Aboriginal and Torres Strait Islander health everybody’s business’534

Figure 14.10: Enablers and constraints to achievement of complementary linkages with other ICDP funded programs established – including collaboration between sectors536

Figure 17.1: Mechanisms through which effective implementation of the Indigenous Chronic Disease Package is achieved551

Figure 17.2: Enablers and constraints to a systems approach to developing and engaging the workforce552

Figure 17.3: Enablers and constraints to a systems approach to developing and optimising chronic disease service delivery systems557

Figure 17.4: Enablers and constraints to orientation of primary health care organisations to Aboriginal and Torres Strait Islander community needs and values and to chronic illness care562

Figure 17.5: Enablers and constraints to primary health care organisations engaging with ICDP measures and utilising them effectively within existing systems567

Figure 17.6: Enablers and constraints partnering and mobilisation within and across organisations and sectors to achieve relevant ICDP goals and outcomes571

Figure 17.7: Enablers and constraints to aligning core values with best practice in Aboriginal and Torres Strait Islander primary health care576

Figure 17.8: Enablers and constraints to complementary linkages between programs/ activities/ service579

Tables

Table 2.1: Priority areas, measures and funding under the Indigenous Chronic Disease Package, 2009–201320

Table 2.2: Number of interviews held in Sentinel Sites, by evaluation cycle27

Table 2.3: Number of attendees at community focus groups held in case study sites, by evaluation cycle27

Table 2.4: Number of Health Services that provided clinical indicator data, by evaluation cycle, and sector28

Table 2.5: Sentinel Site locations, population numbers and key stakeholder organisations31

Table 3.1: Regional Tackling Smoking and Healthy Lifestyle team allocation and recruitment in Sentinel Sites, March 2011 – October 201242

Table 3.2: Trends in managers’ and clinicians’ awareness of Regional Tackling Smoking and Healthy Lifestyle workforce (% who responded ‘yes’), overall and by sector54

Table 3.3: Trends in clinicians’ perceived changes in client behaviour (% who responded ‘strongly agree’ or ‘partly agree’), overall and by rurality61

Table 3.4: Clinical indicators provided by Health Services for Aboriginal and Torres Strait Islander people63

Table 3.5: Summary of key findings in relation to the program logic – National Action to Reduce Aboriginal and Torres Strait Islander Smoking Rates and Helping Indigenous People Reduce their Risk of Chronic Disease measures72

Table 4.1: Local Community Campaign activity in Sentinel Sites 2010–201285

Table 4.2: Trends in awareness and perceptions of centrally supplied resources (% of managers and clinicians who responded ‘strongly agree’ or ‘partly agree’)90

Table 4.3: Summary of key findings in relation to the program logic – Local Indigenous Community Campaigns to Promote Better Health measure97

Table 5.1: Cumulative trends in uptake of the PBS Co-payment measure by Health Service, patient and numbers of pharmacies participating (1 July 2010 – 30 June 2012)102

Table 5.2: Awareness of the PBS Co-payment measure for medicines available for Aboriginal and Torres Strait Islander people (% who responded 'yes'), overall and by rurality105

Table 5.3: Trends in perceptions and awareness of the PBS Co-payment measure (% who responded ‘strongly agree’ or ‘partly agree’), overall108

Table 5.4: Summary of key findings in relation to program logic – PBS Co-payment measure153

Table 6.1: Number of adult health assessments (MBS items 704, 706, 710 to 1 May 2010 thereafter 715) claimed per Aboriginal and Torres Strait Islander people aged ≥15 years for Sentinel Sites and the rest of Australia, March 2009 – May 2012163

Table 6.2: Follow-up services provided by a practice nurse or registered AHW to Aboriginal and Torres Strait Islander people aged ≥15 years who received an adult health assessment (MBS items 10987), in Sentinel Sites and the rest of Australia, by quarter, March 2009 – May 2012188

Table 6.3: Follow-up allied health services among Aboriginal and Torres Strait Islander people aged ≥15 years who have received an adult health assessment (MBS items 81300–81360) in Sentinel Sites and the rest of Australia, by quarter, March 2009 – May 2012195

Table 7.1: Number of Health Services that have received the payment for the PIP Indigenous Health Incentive sign-on payment for Sentinel Sites and the rest of Australia by urban, regional or remote location, sector, and quarter, March 2010 – May 2012227

Table 7.2: Trends in perceptions of ease of access to the PIP Indigenous Health Incentive (% who responded ‘strongly agree’ or ‘partly agree’), overall and by location235

Table 7.3: Trends in perceptions of the new PIP Indigenous Health Incentive as causing a large administrative workload (% who responded ‘strongly agree’ or ‘partly agree’), overall and by location236

Table 7.4: Summary of key findings in relation to the program logic – PIP Indigenous Health Incentive measure301

Table 8.1: Trends in perceptions of ICDP funded Care Coordination and Supplementary Services (% who responded ‘strongly agree’ or ‘partly agree’), overall and by rurality312

Table 8.2 Progress with recruitment to Care Coordinator positions in Sentinel Sites315

Table 8.3: Trends in managers’ and clinicians’ awareness of the availability of Supplementary Services funding (% who responded ‘yes’), overall and by rurality and sector327

Table 8.4: Summary of key findings in relation to the program logic – Care Coordination and Supplementary Services measure339

Table 9.1: Flinders chronic disease self-management training participant numbers at 31 December 2011 and 31 August 2012347

Table 9.2: Summary of key findings in relation to program logic – helping Indigenous People Self-manage their Risk of Chronic Disease measure362

Table 10.1: Trends in managers and clinicians perceptions of USOAP service within relevant Sentinel Site (% who responded ‘strongly agree’ or ‘partly agree’)369

Table 10.2 Number of Sentinel Sites in which various types of health professionals were funded through Urban Specialist Outreach Assistance Program to 30 June 2012370

Table 10.3: Summary of key findings in relation to program logic – Urban Specialist Outreach Assistance Program measure390

Table 11.1: Trends in perceptions of MSOAP-ICD service (% who responded ‘strongly agree’ or ‘partly agree’), overall400

Table 11.2: Number of Sentinel Sites in which various types of health professionals were funded through MSOAP-ICD from 1 July 2010 – 30 June 2012404

Table 11.3: Summary of key findings in relation to the program logic –Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease measure424

Table 12.1 Number of Outreach Workers that completed orientation by quarter, and jurisdiction, 2011–2012431

Table 12.2: Summary of key findings in relation to the program logic – Workforce Support, Education and Training measure463

Table 13.1: Numbers of Outreach Workers, practice managers and additional health professionals funding allocation nationally, by funding allocation period468

Table 13.2: Outreach Worker allocation and recruitment in Aboriginal Health Services, over time and by urban, regional and remote locations, March 2011 – October 2012470

Table 13.3: Trends in awareness of Outreach Worker in the Aboriginal Health Service (% who responded ‘yes’) overall and by sector and geographic location in Sentinel Sites472

Table 13.4: Trends in perceptions of the role and contributions of Outreach Workers based in AHS and DGP (% who responded ‘strongly agree’ or ‘partly agree’), overall and by sector479

Table 13.5: Practice manager and additional health staff allocation and recruitment in Sentinel Sites, over the evaluation periods, March 2011 – October 2012486

Table 13.6: Summary of key findings in relation to the program logic – Expanding the Outreach and Service Capacity of Indigenous Health Services measure495

Table 14.1: Indigenous Health Project Officer and Outreach Workers allocation and recruitment by evaluation period and by urban, regional and remote Sentinel Sites, February 2011 – October 2012506

Table 14.2: Awareness of Indigenous Health Project Officer (% who responded ‘yes’) overall and by urban, regional and remote location510

Table 14.3: Awareness of Outreach Worker (% who responded ‘yes’) overall and by rurality512

Table 14.4: Responses to the statement 'Local Aboriginal and Torres Strait Islander people are attending Health Services more regularly as a result of the work of the Outreach Worker' (% who responded ‘strongly agree’ or ‘partly agree’), by sector515

Table 14.5: Summary of key findings in relation to the program logic – Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care measure538

Table 17.1: Summary of key findings in relation to the program logic – Indigenous Chronic Disease Program582

iii

Abbreviations

The following abbreviations are used in this document:

ABSAustralian Bureau of Statistics

ACCHOAboriginal Community Controlled Health Organisation

ACCHSAboriginal Community Controlled Health Service

ACTAustralian Capital Territory

AGPNAustralian General Practice Network

AHSAboriginal Health Service

AHWAboriginal Health Worker

CCSSCare Coordination and Supplementary Services

CDSMChronic Disease Self-Management

CtGClosing the Gap

CHAPCommunity Health Action Pack

DGPDivision of General Practice

DoHADepartment of Health and Ageing

FTEFull-time Equivalent

GPGeneral Practitioner

GPMPGP Management Plan

HLWHealthy Lifestyle Workers

ICDPIndigenous Chronic Disease Package

IHPOIndigenous Health Project Officer

LCCLocal Community Campaigns

MAHSMore Allied Health Service

MBSMedicare Benefits Schedule

MSOAP-ICDMedical Specialist Outreach Assistance Program – Indigenous Chronic Disease

NACCHONational Aboriginal Community Controlled Health Organisation

NRNot reported

NRTNicotine Replacement Therapy

NSWNew South Wales

NTNorthern Territory

OATSIHOffice for Aboriginal and Torres Strait Islander Health

OWOutreach Worker

PBSPharmaceutical Benefits Scheme

PHCPrimary Health Care

PIPPractice Incentives Program

QldQueensland

QUMAXQuality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People

RTCRegional Tobacco Coordinator

S100Section 100

SASouth Australia

SBOState Based Organisations

SLAStatistical Local Area

SSESentinel Sites Evaluation

RPHSRural Primary Health Service

TasTasmania

TAWTobacco Action Worker

TCATeam Care Arrangement

USOAPUrban Specialist Outreach Assistance Program

VicVictoria

WAWestern Australia

Acknowledgments

Authors of this report: Ross Bailie, Jodie Griffin, Margaret Kelaher, Tracy McNeair, Nikki Percival, Alison Laycock and Gill Schierhout.

All authors were involved in reviewing and finalising this evaluation report.

The report is based on vital contributions from all members of the Sentinel Sites Evaluation team, whose roles and contribution are listed below.

We sincerely thank the range of employees of key stakeholder organisations, community members and individuals in the Sentinel Sites for their generous contributions to the evaluation.

Special thanks to the staff of the Australian Government Department of Health and Ageing for their support in providing program and administrative data for this report and for their assistance regarding interpretation of these data.

The Sentinel Sites Evaluation Team

The Menzies School of Health Research staff:

Ross Bailie (Project Leader)— Overall leadership of project, including development of the evaluation design, oversight of data collection, analysis and reporting.

Marcus Goddard (Program Director)— High-level leadership and advice.

Marianne Hellers (Project Manager)— Leadership and management of project team and project schedule, and contribution to report preparation.

Jodie Griffin (Evaluation Process Coordinator)— Major role in data analysis, writing, reviewing and coordinating preparation of the report. Contribution to collection and management of data. Development and refinement of evaluation tools and processes.

Tracy McNeair (Evaluation Process Coordinator)— Major role in collation, analysis and reporting of program and administrative data. Contribution to the data collection and report preparation.

Katherine Moore (Site Evaluation Manager)—Provided leadership in site engagement and oversight of the site evaluation team.

Barbara Beacham (Site Evaluation Manager)— Major role in management of site evaluation team and coordination of data collection processes. Contribution to data collection, analysis and interpretation, and report preparation.

Amal Chakraborty, Trish Hickey, Elaine Kite, Lynette O’Donoghue, Julia Hodgson, Kevin Swift (Site Evaluation Facilitators)— Major role in data collection. Contribution to data analysis and interpretation, and report preparation. Advice on evaluation design, tools and processes as a consultant (Lynette). Assistance with data collection, compilation and analysis of clinical indicator data (Kevin and Amal).

Jennifer Allchurch, Andrea Moser (Administrators)— Major role in document control, formatting, and quality assurance. Compilation of data tables and management of database (Jen).

Nikki Percival (Consultant)—Major role in qualitative data analysis and report writing. Expert advice on health promotion.

Alison Laycock (Consultant)— Major role in data analysis, interpretation and report writing.

Gill Schierhout (Consultant)— Major role in data analysis, interpretation and report writing.

Barry Scrimshaw (Consultant)— Database consultant.

Julie Brimblecombe, Leisa McCarthy, David Thomas (Consultants)— Advice on evaluation design, tools and processes, and reviewing chapters of the report (David).

The University of Melbourne staff:

Margaret Kelaher (Administrative Data Consultant) — Lead role in administrative (MBS, PBS and PIP) data analysis, interpretation and report preparation.

Zewdu Woubalem Wereta (Administrative Data Officer) — Assistance with the process of collating, analysing and reporting administrative data.

Ian Anderson, Kevin Rowley (Consultants) — Advice on stakeholder engagement and evaluation design, and reviewing chapters of the report (Kevin).

Suggested Citation:

Bailie R, Griffin J, Kelaher M, McNeair T, Percival N, Laycock A, Schierhout G, 2013, Sentinel Sites Evaluation: Final Report. Report prepared by Menzies School of Health Research for the Australian Government Department of Health, Canberra.

Sentinel Sites Evaluation Final Report – February 2013

Definitions

For the purposes of this report:

1. ‘Aboriginal Health Service’ refers to Aboriginal Community Controlled Health Organisations, State/Territory managed Aboriginal Health Services and other non-community controlled Aboriginal Health Services designed primarily to meet the needs of Aboriginal and Torres Strait Islander people. All except one of the AHSs were Aboriginal Community Controlled Health Organisations.

‘Aboriginal Health Sector’ includes Aboriginal Health Services and NACCHO State/Territory affiliates.

‘Adult health assessments’ refers to claims made for Aboriginal and Torres Strait Islander health assessments (MBS items 704, 706, 710 and, after 1 May 2010, 715) by people aged ≥15 years.

‘Chronic illness care’ is used in preference to ‘chronic disease care’ or ‘chronic disease management’ except where quoting or referring to official documentation. The term ‘chronic illness’ is more reflective of a person’s experience of care and is used in favour of the more medical term ‘chronic disease’. This is consistent with contemporary approaches or concepts, such as the chronic care model, patient/client centred care, and holistic care.

‘Clinician’ refers to a health professional such as a general practitioner (GP), nurse or Aboriginal Health Worker.

‘Division of General Practice’ may also refer to the Medicare Locals. It is recognised that Divisions of General Practice are at varying stages of transitioning.

’General Practice’ refers to privately run General Practices.

‘General Practitioner (GP)’ refers to medical doctors based in both private General Practice and Aboriginal Health Services.

‘General Practice Sector’ includes private General Practice, Division of General Practice and State Based Organisations.

‘Health Service’ refers to any primary health care services, including General Practices and Aboriginal and Torres Strait Islander Health Services.

‘Indigenous’ is used when referring to the Indigenous Chronic Disease Package measures as per the usage in Commonwealth Government documents. The term should be read to be synonymous with the phrase ‘Aboriginal and Torres Strait Islander as used elsewhere in the report.

‘Measure’ refers to programs addressing the priority areas as part of the Indigenous Chronic Disease Package.

‘Measure manager’ refers to a Department of Health and Ageing program manager for a specific ICDP measure.

‘National Framework’ refers to the National Monitoring and Evaluation Framework that was developed to guide the ongoing monitoring and evaluation of the Indigenous Chronic Disease Package measures.

‘Regional Tackling Smoking and Healthy Lifestyle teams’ refer collectively to the following ICDP funded workers: Regional Tobacco Coordinator, Tobacco Action Worker and Healthy Lifestyle Worker.

'Sentinel Site' refers to a geographically defined area that is the focus of 'place-based' Sentinel Sites Evaluation activities.

‘State-wide organisation’ refers to organisations that have State-wide responsibilities such as Divisions, State Based Organisations, Workforce Agencies, NACCHO State/Territory affiliates.

For the purposes of this report we will continue to refer to DGPs, recognising that by the time of this Final Report is released all Divisions of General Practices’ have transitioned to a Medicare Local.

Where reference is made to data from ‘the Sentinel Sites and the rest of Australia’, data are aggregated for all the relevant Sentinel Sites, and for the rest of Australia excluding the Sentinel Sites respectively.

Guide to reading this report

This report is designed to be useful for people working in a range of roles that may have relevance to the Indigenous Chronic Disease Package (ICDP), and who may have an interest in the findings of the Sentinel Sites Evaluation (SSE). Given the objective of the report to inform wider and ongoing implementation, the managers within the Department of Health and Ageing (DoHA) responsible for implementation of each of the measures are a key target audience. The findings are, therefore, presented separately for each of the measures.

The report assumes a reasonable level of knowledge about the ICDP and about the measures that make up the ICDP. It includes references to sources of information about the ICDP in general and about specific measures.

It is clear that the extent to which measures are complementary and mutually reinforcing is a major determinant of the success of individual measures and of the ICDP as a whole. Therefore, we encourage readers to engage with the report overall, as this will assist in understanding how measures can be refined and implemented in a way that enhances the ICDP’s effectiveness in various settings across Australia.

The report is made up of three sections: the executive summary, main report and appendices.

1. The executive summary reflects the key messages and findings from the SSE.

1. The main report describes the findings over the course of the evaluation in relation to the SSE’s key objectives. The findings for each specific measure area are presented in the order they appear in the ICDP design, followed by a chapter on the findings of the evaluation of the ICDP as a whole.

1. Each of the ‘measure’ chapters provides:

1. A brief overview of the measure and, based on information provided by DoHA, a summary of the state of its implementation at a national level.

1. A description of the findings relevant to the measure based on thematic analysis of data from the Sentinel Sites.

1. An analysis of ‘what works for whom under what conditions’ in a variety of local contexts in relation to each measure.

1. An analysis of progress with implementation in relation to the program logic for each measure as specified in the National Monitoring and Evaluation Framework (from here on the ‘National Framework’).[footnoteRef:2] [2: Urbis, ICDP Monitoring and Evaluation Framework, September 2010 (accessed 21 November 2012).]

1. The chapter on the whole-of-ICDP is structured in line with the last two dot points above, but from a whole-of-ICDP perspective and in relation to the outputs and results for the ICDP (as specified in the National Framework). It provides insight into the higher level issues that are affecting success with implementation of the overall ICDP in a variety of local contexts and those issues that need to be addressed and monitored during the process of ongoing implementation.

1. The appendices contain more detailed information on the background, evaluation methods and analysis of the data presented in the main report.

The scope and complexity of the ICDP, the large number of indicators in the National Framework (Appendix A) and the qualitative nature of many of the indicators result in a lengthy report. We have endeavoured to make it as concise and readable as possible while at the same time dealing with a wide range of important issues in sufficient detail to deliver a meaningful and useful evaluation.

The information presented in this report reflects the best available data at the time of the final evaluation cycle. New data, or refinements to evaluation processes over time, mean there are some differences between this and previous reports.

9

Executive summaryIntroduction

Chronic disease contributes to two-thirds of the health gap between Aboriginal and Torres Strait Islander people and other Australians. The Indigenous Chronic Disease Package (ICDP) is a vitally important initiative that was designed to improve the capacity of primary health care services to more effectively prevent and manage chronic disease for Aboriginal and Torres Strait Islander people. The Sentinel Sites Evaluation (SSE) has shown some notable achievements of the ICDP to date:

improved access to primary health care services and to affordable medication for many Aboriginal and Torres Strait Islander people;

improved orientation of the General Practice sector to the needs of Aboriginal and Torres Strait islander people;

significant steps towards the early establishment of a new workforce that is focused on health promotion and in development of local health promotion initiatives; and

increased attention to enhancing access to specialist, allied health and team-based approaches to chronic illness care.[footnoteRef:3] [3: We use the term ‘chronic illness care’ to emphasise the importance of people’s experience of care. See further explanation in the definitions list.]

The ICDP was funded over four years from 2009–2013 and represents the Australian Government’s contribution of $805.5 million to the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. The funding supported implementation of 14 measures across three priority areas:

1) tackling chronic disease risk factors

2) earlier detection, improved management and follow-up of chronic diseases in primary health care

3) expansion of the Aboriginal and Torres Strait Islander workforce and increased capacity of the health workforce to deliver effective care.[footnoteRef:4] [4: For more information on the ICDP (accessed 16 October 2013).]

The measures include a range of health promotion and social marketing activities, training, reforms to existing programs, and new initiatives and funding both to improve follow-up and coordination of care and to increase the size and capacity of primary care services to deliver effective care to Aboriginal and Torres Strait Islander people.

In 2010, the Department of Health and Ageing (DoHA) contracted Menzies School of Health Research (Menzies) to undertake a place-based monitoring and formative evaluation of the ICDP through the SSE to inform ongoing refinements in design and implementation of the package.

Evaluation process and methods

Twenty-four Sentinel Sites were established through engagement with Aboriginal Health Services (AHS) and the Division of General Practice (DGP) as key stakeholders. Sites were distributed across all States and Territories in urban, regional and remote locations. Location of sites was determined by DoHA in consultation with Aboriginal and Torres Strait Islander Health Partnership Forums in each State/Territory. Ethical approval for the SSE was obtained through a specially established ethics advisory group, and subsequently through the DoHA Ethics Committee.

The SSE comprised five six-monthly cycles of data collection, analysis, interpretation and reporting. Administrative and program data available through DoHA were collated and analysed for all 24 sites. Eight sites were designated as case study sites, with relatively intensive data collection processes. These included semi-structured interviews with a range of key informants and community focus groups with community members. A further eight sites were designated as enhanced tracking sites, where open-ended interviews were conducted with a smaller range of selected key informants. Clinical indicator data were requested from General Practices and AHSs in the 16 case study and enhanced tracking sites.

Analysis of the data gathered during the evaluation period was specifically designed to address the SSE objectives. These included describing ICDP implementation, identifying and tracking change and identifying the constraints and enablers impacting on effective implementation of the ICDP at the local level. Findings of the SSE need to be interpreted with an understanding that the sites were not intended to be representative of the range of service settings across Australia.

Overview of findings

Over the course of the SSE 684 interviews were completed with key informants in case study sites, 72 community focus groups conducted with a total of 670 participants, and 41 Health Services provided clinical indicator data.

There has been steady progress with the implementation of the ICDP. The SSE has found evidence of activity at a local level for almost all measures across the three priority areas identified above.

The findings of the SSE should be interpreted in relation to its intended purpose; namely to inform ongoing improvements, refinements in design and implementation of the ICDP. As intended, the innovative evaluation approach of the SSE has enabled early identification of barriers and enablers to implementation to inform refinement and ongoing implementation at the local, regional and policy level.

Tackling chronic disease risk factors

The measures under this priority area were designed to address key risk factors associated with the development of chronic diseases, including tobacco smoking, poor nutrition and lack of exercise. The measures supported the development of community education initiatives, the establishment of a new tobacco and healthy lifestyle workforce, development of lifestyle modification programs and improved access to quit smoking programs.[footnoteRef:5] [5: For more information on the individual measures that address this priority area see DoHA, Closing the Gap, Tackling Chronic Disease Risk Factors (accessed 4 March 2013).]

National action to reduce smoking rates and reduce risk of chronic disease measures

As major component of this measure Regional Tackling Smoking and Healthy Lifestyle teams are being established across the majority of Sentinel Sites, with almost all teams based in AHSs. There was a high level of engagement by the teams in various training activities funded through the measure and considerable activity in the development and distribution of toolkits and resources to support the workforce in their roles. There was increasing awareness of the teams over the course of the SSE, and the design and delivery of programs and services gained momentum. The program of work delivered by teams varied across sites and included health education, locally developed social marketing campaigns and community activities, implementation of smoke-free workplace policies, and group and individual support. A range of local factors, including organisational capacity and partnerships to provide effective support to the teams, influenced the extent to which teams were able to function effectively.

Priority issues to address in ongoing implementation include the need for greater awareness of these teams across regional areas, clearer understanding of their community development and outreach role and greater connection with the General Practice sector. Teams also need to engage with and define their complementary roles with primary health care clinical teams, and expand their population coverage – including through supporting more local community-based initiatives. There is a need to ensure that centrally produced resources are suited to local settings. Ongoing evaluation and improvement efforts should ensure that initiatives are integrating evidence-based principles, that they are achieving the intended outcomes, and that initiatives are refined in the light of good evaluation evidence.

Local Community Campaigns to promote better health measure

There was increasing awareness of grant funding availability, and evidence of project-level activities related to the targeted (first round) grant funding. There was no evidence of activity relating to the competitive (second) grant round, as funding had only recently been awarded. Perceptions of Healthy Community Days were generally positive. There were existing high levels of awareness among community members of the risk factors for chronic disease.

Priority issues to address in ongoing implementation of this measure include the development of strategies to identify and reach particular target population groups, and to move beyond education about risk factors to promotion of personal and population-level risks to health (i.e., factors in the physical and social environment that influence health behaviour and exposure to health risks), and effective ways to reduce that risk. Also needed is an evaluation of which activities funded through the measure are based on best evidence and are achieving their intended outcomes, and ongoing refinement of these in the light of this evidence.

Early detection, improved chronic disease management and follow-up care

Measures under this priority area were to deliver a comprehensive chronic disease management program through increasing uptake of adult health assessments and follow-up care in a coordinated, accessible and systematic manner. Incentives were provided to encourage Health Services to improve the coordination of health care, and promote best practice management of patients with chronic disease. Support was to be provided to enable Aboriginal and Torres Strait Islander people to be active participants in their own health care. This priority area also included measures to improve access to medicines, multidisciplinary follow-up care and specialist services.[footnoteRef:6] [6: For more information on the individual measures that address this priority area see DoHA, Closing the Gap, Improving Chronic Disease Management and Follow Up (accessed 4 March 2013).]

Subsiding Pharmaceutical Benefits Scheme (PBS) medicine co-payments measure

The numbers of people registered for the PBS Co-payment exceeded expectations, and appeared to be encouraged by community demand and practitioners’ perceptions of the value of the measure. High levels of awareness of the PBS Co-payment measure were evident in urban and regional sites, with lower but increasing awareness in remote sites. There was wide variation in uptake of the measure between specific Sentinel Sites and across urban, regional and remote locations, with exceptionally high uptake in a small number of locations. There was no evidence of systematic processes at the local level to ensure that the measure was providing benefit to those in most need. The data suggest that the PBS Co-payment measure is reaching many of those with relatively high need, but not necessarily those most likely to be affected by financial barriers.

Priority issues to address to ongoing implementation include improving the understanding and engagement of specialists, pharmacists, hospital staff and service providers in remote locations in supporting eligible patients to gain access to the benefits of the PBS Co-payment measure. The definition and application of eligibility for the PBS Co-payment measure should be reviewed and revised in a way that ensures the measure provides benefit to those patients and families most in need.

Higher utilisation costs for Medicare Benefits Schedule (MBS) items measure

Uptake of adult health assessments in the Sentinel Sites increased almost four-fold over the evaluation period, and two-fold in the rest of Australia. There was wide variation in uptake with the highest levels occurring in sites with high numbers of General Practitioners (GPs) conducting adult health assessments and, to a lesser extent, high numbers of assessments being completed by each GP. There appeared to be limited awareness of the ICDP-related follow-up items, and limited organisational and system capacity to take advantage of these items – particularly in those services most in need of support.

The number of claims for follow-up services by practice nurses and registered Aboriginal Health Workers (AHWs) was considerably lower than the uptake of health assessments, although there were some indications of increasing claims over the course of the SSE. Uptake of follow-up services by allied health professionals showed a similar pattern. Appropriate follow-up of health assessments is vital for these assessments to translate into improved quality of care and health outcomes.

Priority issues to address for ongoing implementation include refining the approach to adult health assessments in order to maximise the potential health benefits for patients and populations. Refinements in design should aim to enhance community and population access to health assessments, ensure fit with the variety of primary health care service delivery systems and with health professional perspectives of high-quality primary care, and have appropriate follow-up care. There is a need to improve systems for ongoing evaluation and refinement of approaches to adult health assessments and follow-up care to maximise health benefits to patients and populations.

Practice Incentive Program (PIP) Indigenous Health Incentive measure

There were high levels of awareness of, and registration of Health Services for, the PIP Indigenous Health Incentive in urban and regional sites, with lower but increasing awareness in remote sites. The number of people registered for the incentive increased over the evaluation period, with earlier registration through AHSs, and more recent increases mainly through General Practices. Registration for the PIP Indigenous Health Incentive was largely driven by interest in accessing the benefits of the PBS Co-payment measure, as first-time registration for these measures was generally done at the same time. Almost one-third of registered patients did not attend any Health Service sufficiently frequently to trigger a Tier 2 payment (i.e., they did not attend any one service five times or more within a calendar year), or Health Services were not billing for providing care in a way that triggers payments. This raises questions about the specification and application of the eligibility criteria for the incentive and the ability of the current payment system to appropriately reward services for delivery of high quality care. Re-registrations for the PIP Indigenous Health Incentive in subsequent years have been limited (between 30–40% overall), raising further questions about the design and application of this measure.

In association with this measure, access and uptake of cultural awareness training by General Practice staff increased over the evaluation period, with evidence of General Practices becoming more oriented to Aboriginal and Torres Strait Islander patient needs. However, there is little evidence that funding derived from the incentive payments is being used to enhance systems to provide high-quality chronic illness care, although there is some indication of a shift to a more planned or coordinated approach.

Priority considerations for refinement and ongoing implementation of this measure include the need to a) link the registration process more directly to care delivery processes and to health benefits for patients and populations, and b) support system capability to deliver high-quality chronic illness care. Specifically, this includes those services most in need of support for system development; enhancing efforts to build the cultural competence of General Practice; and establishing systems for ongoing evaluation and improvement in order to maximise health benefits to patients and populations.

Care Coordination and Supplementary Services measure

The extent of collaborative development of local Care Coordination and Supplementary Services (CCSS) program arrangements varied between sites. While the guidelines emphasised that the funding could be used in different ways to meet local needs, employment of a nurse as a ‘Care Coordinator’ based in the DGP or Medicare Local (less commonly in an AHS) was the usual model. Recruitment and establishment of Care Coordinators in their role was slow initially. Although the program was generally positively regarded, there were substantial difficulties in establishing appropriate processes for the referral and transitioning of patients. There was also some concern about equity of access for patients, population coverage, complementarity with other initiatives to enhance coordination of care, role definition and sustainability of the model.

Priority issues to address for refinement and ongoing implementation include effective integration of Care Coordinators into clinical teams and maximising the potential for linkages and complementarity with other aspects of the ICDP. This would include clarifying the role of the Care Coordinator in relation to that of other local primary health care team members, refining approaches to use of Supplementary Services funding to maximise potential benefit, strengthening self-management training, and improving complementarity with ICDP-related initiatives to enhance access to specialist care. Reporting frameworks need to be refined to reflect the range of important care coordination activities, linkages and expected outcomes, with development of systems for ongoing evaluation and improvement.

Improving participation in health care through chronic disease self-management measure

Participation in the Flinders Chronic Disease Self-Management (CDSM) training was low in the Sentinel Sites with no clear trends in awareness of the availability of the training across geographical locations. Lack of participation in the Flinders CDSM training in the Sentinel Sites was partly due to a lack of interest in self-management approaches among some service providers, and use of other self-management models in some locations. In sites where training had occurred it did not appear to have effectively reached staff who were in a position to utilise the skills with patients. Those who attended training were not necessarily in a position to influence uptake of the Flinders CDSM tools and techniques by colleagues. This is not necessarily an accurate reflection of the national situation.

In one site the AHS has been actively implementing the Flinders CDSM model, and has integrated self-management work into other care coordination type activities. In some sites the Care Coordinators, predominately those based in DGPs, took up the Flinders CDSM training with enthusiasm and incorporated self-management principles into aspects of their work.

Priority issues to address for ongoing implementation of this measure include adaptation and development of models to enable effective self-management approaches to be applied in everyday service environments, backed by sound evaluation and refinement to maximise potential benefits for patients and populations most in need of support.

Urban Specialist Outreach Assistance Program measure

Access to specialists through the Urban Specialist Outreach Assistance Program (USOAP) varied between Sentinel Sites, influenced by funding allocation processes, availability of services through other programs and having specialists willing to bulk-bill. AHSs hosted the program in all of the participating sites. The recruitment and engagement of specialists was largely complete at the time of the final evaluation visits with some retention difficulties becoming apparent – this was commonly related to low numbers of referrals and patient attendance for appointments. Where referrals were being made, and patients were attending, the USOAP services appeared to be working well for primary health care services, specialists and those patients attending the service. Increased accessibility and confidence in relation to accessing specialist care was noted by some patients who attended AHS-hosted USOAP services. There was a trend towards engaging general physicians over specialists from a specific field of medicine owing to the wider scope of services they could provide.

Priority issues to address for ongoing implementation include strengthening processes for referral (especially from General Practice) and supporting patient attendance at appointments, including through the use of Outreach Workers (OWs). There also needs to be orientation for specialists in the organisational culture of AHSs and effective ways of working in these organisations; enhanced access to specialised equipment and follow-up care and procedures; and systems developed for ongoing evaluation and improvement.

Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease measure

Access to health professionals, including specialists, varied substantially between sites. Most eligible sites were accessing program funding for this measure by the final evaluation cycle, although implementation was at a fairly early stage. The effectiveness of planning processes in ensuring that local needs were addressed was variable, partly due to the limited supply of relevant specialists. Some recruitment strategies put in place by workforce agencies were perceived by AHS interviewees to be overly driven by the availability and interest of visiting health professionals – and not necessarily responsive to local needs for service delivery.

The Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease (MSOAP-ICD) measure resulted in improved patient access to specialists in some sites. However, overall efficiency was questioned, with few referrals and low patient attendance for many services. Specialist appointments, in particular, were influenced by the capacity of the host organisation to coordinate visits and support patient attendance (including recall and reminder systems, clinic management and transport arrangements).

In addition to those identified above for USOAP, priority issues to address for ongoing implementation of MSOAP-ICD include clearer delineation of expectations, roles and responsibilities for the health professional and the host organisation prior to commencement of service delivery, effective approaches to enhancing the capacity of host organisations to coordinate visits, and adequate resourcing to support patients to attend for specialist care in regional or urban centres.

Fixing the gaps and improving the patient journey

Measures under this priority area aimed to expand the primary care workforce in both AHSs and General Practice, and to encourage uptake of health services by Aboriginal and Torres Strait Islander people.[footnoteRef:7] [7: For more information on the individual measures that address this priority area see DoHA, Closing the Gap, Work Expansion. Training and Support (accessed 4 March 2013).]

Workforce support, education and training measure

Staggered recruitment, diversity in skill level, different needs across a variety of work environments and the dispersion of OWs presented significant challenges in providing them with orientation – especially remote-based OWs. Delays in roll-out of orientation packages, however, did lead to opportunities for transfer of learning from more experienced OWs to new workers.

Generally, there was a low uptake of funding for individualised training across the sites. This could be due to a lack of organisational capability to define and source relevant training, as well as uncertainty over contracts. Uptake of the ICDP funded GP Registrar positions in Sentinel Sites was also low, because there were more posts available than AHSs with the capacity to accommodate and provide appropriate supervision, and not enough GP Registrars to fill them.

There was little evidence from the Sentinel Sites that the ICDP funded scholarships for the professional development of nurses in AHSs and scholarships for nurses undertaking a clinical placement in an AHS had created opportunities not previously available. Similarly, the uptake of scholarships for nurses undertaking a clinical placement in an AHS was low, at least partly due to a lack of capacity by AHSs to host and house them.

Priority issues to address for ongoing implementation include the need to increase the feasibility and desirability of GP Registrar posts in AHSs, especially the development of alternative high-quality models of supervision to overcome the current shortage of qualified supervisors in AHSs and the infrastructure to accommodate trainees and support AHSs to coordinate their positions. There is also a need to focus ICDP-related training, scholarships and placements on the strengthening of core competencies for chronic illness care, and to develop systems for ongoing evaluation and refinement to ensure that these initiatives are meeting priority needs.

Expanding the outreach capacity of Aboriginal Health Services measure

There were high levels of recruitment to OW positions in AHSs, with some evidence of greater challenges experienced in recruitment and retention in remote sites. The people recruited to OW positions varied in skills and experience, and filled a range of roles depending on their skills and the need of the AHS. OWs strengthened the efforts of AHSs to improve accessibility to communities through a range of activities.

ICDP funded practice manager

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