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National Monitoring and Evaluation of the Indigenous Chronic Disease Package

Final Report Volume 2: ICDP Impact on Patient Journey and Service Availability

June 2014

National Monitoring and Evaluation of the Indigenous Chronic Disease Package Volume 2: ICDP Impact on Patient Journey and Service Availability 2014

Online ISBN: 978-1-76007-166-0

Publications approval number: 11038

Copyright Statement:

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© Commonwealth of Australia 2015

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 Communication 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 KPMG Australia, and does not necessarily represent the views of the Australian Government. The evaluation of the Indigenous Chronic Disease Package was commissioned by the Department of Health. This report has been prepared by KPMG Australia.The report’s lead authors were the National Health and Human Services Practice, KPMG.The other major contributors to the report were: Dr Brita Pekarsky of the Baker IDI Heart & Diabetes Institute; and Winangali.KPMG wishes to acknowledge the following stakeholders for their contribution to the evaluation through giving their time and sharing their experiences: the Department of Health, state and territory health departments, the National Aboriginal Community Controlled Health Organisation and its Affiliates, peak bodies, Aboriginal Health Services, Divisions of General Practice/Medicare Locals, the Indigenous Health Partnership Forums, ICDP workers and their fund holder representatives, general practice staff and community members.CitationKPMG 2014, National Monitoring and Evaluation of the Indigenous Chronic Disease Package Volume 2: ICDP Impact on Patient Journey and Service Availability (2014), Australian Government Department of Health, Canberra.

National Monitoring and Evaluation of the Indigenous Chronic Disease PackageVolume 2: ICDP Impact on Patient Journey and Service Availability

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Table of ContentsTable of Contents 3Summary of tables 4Summary of figures 11Glossary 12Key terms 15Executive Summary 161 Introduction 182 The conceptual framework 223 Site specific patient journey and service mapping 284 The baseline patient journey and service system 2315 Final Patient journey mapping and service mapping summary 238Appendices 267

3KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards

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Summary of tablesTable 1: System capacity characteristics and indicators....................................22Table 2: Access characteristics and indicators...................................................25Table 3: Service coordination characteristics and indicators..............................27Table 4: Summary of chronic disease related services provided by the AHS in

site one in 2009-10.....................................................................................30Table 5: Professional attendances and pathology services in 2009-10 for patients

found to be ever registered for PIP Indigenous Health Incentive at June 2011...........................................................................................................35

Table 6: Assessment of site one against the conceptual framework..................37Table 7: ICDP workforce allocation (FTE) within site one 2012-13 (various dates).

................................................................................................................... 41Table 8: Summary of chronic disease related services provided by the

Indigenous organisation in site one for 2009-10 and 2011-12....................44Table 9: Summary of Indigenous health organisation service provision in site one

for 2009-10 and 2011-12............................................................................44Table 10. Site population PIP Indigenous Health Incentive statistics..................45Table 11: Number of Aboriginal and Torres Strait Islander Health Assessments,

providers of Health Assessments and average health assessments per provider, site one, by six month period, 2007 to 2012...............................47

Table 12. Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012...................................................................................................47

Table 13: Number of allied health follow up services for EverIHI patients at site one, by six month period, 2007 to 2012.....................................................48

Table 14. Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site one in 2009-10 (baseline period) and calendar year 2012...........................................................................................................48

Table 15: Number of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site one, by six month period, 2007 to 2012..................................................................................49

Table 16. Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site one in 2009-10 (baseline period) and calendar year 2012.....................................................................................49

Table 17: Number of GP attendances, GP providers and attendances per provider, for EverIHI patients at site one, by six month period, 2007 to 2012...........................................................................................................50


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Table 18. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site one in 2009-10 (baseline period) and calendar year 2012...........................................................................................................50

Table 19. Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI at site one in 2009-10 (baseline period) and calendar year 2012...........................................................................................................50

Table 20: Number of pathology services for EverIHI patients at site one, by six month period, 2007 to 2012.......................................................................51

Table 21: Number of PBS scripts dispensed to EverCtG patients by six month period, site one, 2007 to 2012....................................................................51

Table 22: Assessment of change against the conceptual framework – domain 1: system capacity..........................................................................................57

Table 23: Assessment of change against the conceptual framework – domain 2: access.........................................................................................................58

Table 24: Assessment of change against the conceptual framework – domain 3: service coordination...................................................................................60

Table 25: Summary of population, engagement in PIP Indigenous Health Incentive and Health Assessments in 2009-10...........................................64

Table 26: Summary of chronic disease related services provided by the AHS in site two in 2009-10.....................................................................................66

Table 27: ICDP workforce allocation (FTE) within site two, 2012-13 (various dates).........................................................................................................75

Table 28: Summary of chronic disease-related services provided by the Medicare Local in site two at 2009 and 2013.............................................................77

Table 29: Summary of chronic disease related services provided by the AHS in site two for 2009-10 and 2011-12..............................................................77

Table 30: Summary of AHS service provision in site two for 2009-10 and 2011-12......................................................................................................78

Table 31: Site population PIP Indigenous Health Incentive statistics..................80Table 32. Number of EverIHI patients, Health Assessments and Health

Assessments per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012.....................................................................................81

Table 33. Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site two in 2009-10 (baseline period) and calendar year 2012...........................................................................................................81

Table 34. Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012.....................................................................................82

Table 35: Numbers of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments and average Health Assessments per provider at site two, by six month period, 2007 to 2012............................83


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Table 36. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012...........................................................................................................83

Table 37. Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.......84

Table 38: Numbers of allied health follow up services for EverIHI patients at site two, by six month period, 2007 to 2012.....................................................84

Table 39: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site two, by six month period, 2007 to 2012..................................................................................85

Table 40: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site two, by six month period, 2007 to 2012...........................................................................................................86

Table 41: Numbers of pathology services for EverIHI patients at site two, by six month period, 2007 to 2012.......................................................................86

Table 42: Number of PBS scripts dispensed to EverCtG patients by six month period, site two, 2007 to 2012....................................................................87

Table 43: Assessment of change against the conceptual framework – domain 1: system capacity..........................................................................................90

Table 44: Assessment of change against the conceptual framework – domain 2: access.........................................................................................................91

Table 45: Assessment of change against the conceptual framework – domain 3: service coordination...................................................................................93

Table 46: Summary of population, engagement in PIP Indigenous Health Incentive and Health Assessments in 2009-10...........................................97

Table 47: Assessment provided by Division of General Practice with regard to service coordination.................................................................................100

Table 48: ICDP workforce allocation (FTE) within site three, 2012-13 (various dates).......................................................................................................108

Table 49.Site population PIP Indigenous Health Incentive statistics.................112Table 50: Numbers of Aboriginal and Torres Strait Islander Health Assessments,

providers of Health Assessments and average Health Assessments per provider, site three, by six month period, 2007 to 2012..........................113

Table 51. Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site three in 2009-10 (baseline period) and calendar year 2012...................................................................................114

Table 52: Numbers of allied health follow up services for EverIHI patients at site three, by six month period, 2007 to 2012................................................114

Table 53. Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site three in 2009-10 (baseline period) and calendar year 2012.........................................................................................................114


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Table 54: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site three, by six month period, 2007 to 2012................................................................................115

Table 55. Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site three in 2009-10 (baseline period) and calendar year 2012...................................................................................115

Table 56: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site three, by six month period, 2007 to 2012.........................................................................................................116

Table 57. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site three in 2009-10 (baseline period) and calendar year 2012.........................................................................................................116

Table 58: Numbers of pathology services for EverIHI patients at site three, by six month period, 2007 to 2012.....................................................................117

Table 59. Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.....117

Table 60: Number of PBS scripts dispensed to EverCtG patients by six month period, site three, 2007 to 2012...............................................................118

Table 61: Assessment of change against the conceptual framework – domain 1: system capacity........................................................................................123

Table 62: Assessment of change against the conceptual framework – domain 2: access.......................................................................................................124

Table 63: Assessment of change against the conceptual framework – domain 3: service coordination.................................................................................127

Table 64: Summary of population, engagement in PIP Indigenous Health Incentive and Health Assessments in 2009-10.........................................132

Table 65: Summary of chronic disease related services provided by the AHS in site four in 2009-10..................................................................................134

Table 66: ICDP workforce allocation (FTE) within site four, 2012-13 (various dates).......................................................................................................144

Table 67: Summary of chronic disease related services provided by the Indigenous organisation in site four for 2009-10 and 2011-12.................147

Table 68: Summary of Indigenous health organisation service provision in site four for 2009-10 and 2011-12..................................................................148

Table 69. Site population PIP Indigenous Health Incentive statistics................148Table 70: Numbers of Aboriginal and Torres Strait Islander Health Assessments,

providers of Health Assessments and average Health Assessments per provider, site four, by six month period, 2007 to 2012............................151

Table 71: Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site four in 2009-10 (baseline period) and calendar year 2012...................................................................................151


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Table 72: Numbers of allied health follow up services for EverIHI patients at site four, by six month period, 2007 to 2012..................................................152

Table 73: Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site four in 2009-10 (baseline period) and calendar year 2012.........................................................................................................152

Table 74: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site four, by six month period, 2007 to 2012................................................................................153

Table 75: Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site four in 2009-10 (baseline period) and calendar year 2012...................................................................................153

Table 76: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site four, by six month period, 2007 to 2012.........................................................................................................154

Table 77: Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012...........154

Table 78: Numbers of pathology services for EverIHI patients at site four, by six month period, 2007 to 2012.....................................................................155

Table 79: Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI at site four in 2009-10 (baseline period) and calendar year 2012.........................................................................................................155

Table 80: Number of PBS scripts dispensed to EverCtG patients by six month period, site four, 2007 to 2012.................................................................156





Table 85: ICDP workforce allocation (FTE) within site five, 2012-13 (various dates).......................................................................................................178

Table 86: Summary of chronic disease-related services provided by the Medicare Local in site five at 2009 and 2013...........................................................180

Table 87: Site population PIP Indigenous Health Incentive statistics................182Table 88: Numbers of Aboriginal and Torres Strait Islander Health Assessments,

providers of Health Assessments and average Health Assessments per provider, site five, by six month period, 2007 to 2012.............................183

Table 89: Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site five in 2009-10 (baseline period) and


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calendar year 2012...................................................................................183Table 90: Numbers of allied health follow up services for EverIHI patients at site

five, by six month period, 2007 to 2012...................................................184Table 91: Number of EverIHI patients, Allied health follow ups, Allied health

follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site five in 2009-10 (baseline period) and calendar year 2012.........................................................................................................184

Table 92: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site five, by six month period, 2007 to 2012................................................................................185

Table 93: Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site five in 2009-10 (baseline period) and calendar year 2012...................................................................................185

Table 94: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site five, by six month period, 2007 to 2012.........................................................................................................186

Table 95: Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012...........186

Table 96: Numbers of pathology services for EverIHI patients at site five, by six month period, 2007 to 2012.....................................................................187

Table 97: Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.....187

Table 98: Number of PBS scripts dispensed to EverCtG patients by six month period, site five, 2007 to 2012..................................................................188





Table 103: Summary of chronic disease related services provided in site six.. 202Table 104: Assessment provided by Division of General Practice with regard to

service coordination.................................................................................203Table 105: ICDP workforce allocation (FTE) within site six, 2012-13 (various

dates).......................................................................................................211Table 106: Summary of AHS service provision in site six for 2009-10 and

2011-12....................................................................................................213Table 107: Summary of chronic disease related services provided by the

Indigenous organisation in site six for 2009-10 and 2011-12...................214


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Table 108: Site population PIP Indigenous Health Incentive statistics..............215Table 109: Numbers of Aboriginal and Torres Strait Islander Health Assessments,

providers of Health Assessments and average Health Assessments per provider, site six, by six month period, 2007 to 2012..............................216

Table 110: Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site six in 2009-10 (baseline period) and calendar year 2012...................................................................................217

Table 112: Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site six in 2009-10 (baseline period) and calendar year 2012.........................................................................................................217

Table 114: Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site six in 2009-10 (baseline period) and calendar year 2012...................................................................................217

Table 111: Numbers of allied health follow up services for EverIHI patients at site six, by six month period, 2007 to 2012....................................................218

Table 113: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site six, by six month period, 2007 to 2012................................................................................218

Table 115: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site six, by six month period, 2007 to 2012.................................................................................................................. 219

Table 116: Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site six in 2009-10 (baseline period) and calendar year 2012.................................................................................................................. 219

Table 117: Numbers of pathology services for EverIHI patients at site six, by six month period, 2007 to 2012.....................................................................220

Table 118: Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.........................................................................................................220

Table 119: Number of PBS scripts dispensed to EverCtG patients by six month period, site six, 2007 to 2012...................................................................221

Table 120: Assessment of change against the conceptual framework - domain 1: system capacity........................................................................................225

Table 121: Assessment of change against the conceptual framework - domain 2: access.......................................................................................................226

Table 122: Assessment of change against the conceptual framework-domain 3: service coordination.................................................................................228

Table 123: Changes in different types of MBS services before, during and after the baseline year of 2009-10, by site.......................................................253

Table 124: Number of Aboriginal and Torres Strait Islander Health Assessments for EverIHI patients, by six month period and site, 2007 to 2012.............255


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Table 125: Number of providers of Aboriginal and Torres Strait Islander Health Assessments for EverIHI patients, by six month period and site, 2007 to 2012.........................................................................................................256

Table 126: Average number of Aboriginal and Torres Strait Islander Health Assessments per provider, by six month period and site, 2007 to 2012.. 257

Table 127: Site population and PIP Indigenous Health Incentive registration statistics...................................................................................................258

Table 128: Allied health services by year and site............................................259Table 129: Overview of stakeholders consulted during six patient journey

mapping and service mapping site visits..................................................269Table 130: Data sources utilised to inform patient journey mapping and service

mapping...................................................................................................272Table 131: Methods to inform assessment at different levels..........................278Table 132: Assessment of the changes observed as a result of the ICDP at final

stage.........................................................................................................282Table 133: Assessment of the variable changes observed as a result of the ICDP

at final stage.............................................................................................286Table 134: Commonwealth and State governments' health care funding

responsibilities..........................................................................................291Table 135: Overview of health professionals as of 2012-13.............................292Table 136: Government health policy directions..............................................293Table 137: Overview of the Australian mainstream primary health care system.

................................................................................................................. 293Table 138: Overview of ACCHOs and their service delivery..............................295Table 139: Overview of the Australian secondary care system........................296Table 140: Overview of the Australian secondary care system........................297Table 141: ICDP workforce role (FTE) by remoteness at 31 December 2012 and

31 March 2013 for ATSIOW and IHPO.......................................................297Table 142: ICDP workforce investment by remoteness....................................298Table 143: ICDP workforce investment by organisation type...........................298


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Summary of figuresFigure 1: Patient service map site one: Baseline. ..............................................62Figure 2: Patient service map site one: Final......................................................63Figure 3: Patient service map site two: Baseline................................................95Figure 4: Patient service map site two: Final. ....................................................96Figure 5: Patient service map site three: Baseline............................................130Figure 6: Patient service map site three: Final.................................................131Figure 7: Patient service map site four: Baseline..............................................165Figure 8: Patient service map site four: Final....................................................166Figure 9: Patient service map site five: Baseline..............................................198Figure 10: Patient service map site five: Final..................................................199Figure 11: Patient service map site six: Baseline..............................................229Figure 12: Patient service map site six: Final...................................................230Figure 13: Trend in number of PBS scripts dispensed to EverCtG patients, by 12

month period and site, January 2007 to December 2012 (2007 = 100).. .244Figure 14: Trend in number of EverCtG patients dispensed a PBS script, by 12

month period and site, January 2007 to December 2012 (2007 = 100).. .246Figure 15: Trend in number of PBS scripts per EverCtG patient dispensed a PBS

script, by 12 month period and site, January 2007 to December 2012 (2007 = 100)......................................................................................................246

Figure 16: Trend in number of PBS Drugs Used in Diabetes scripts dispensed to EverCtG patients, by 12 month period and site, January 2007 to December 2012 (2007 = 100)...................................................................................247

Figure 17: Trend in number of EverCtG patients dispensed a PBS Drugs Used in Diabetes PBS script, by 12 month period and site, January 2007 to December 2012 (2007 = 100)..................................................................248

Figure 18: Trend in number of PBS Drugs Used in Diabetes scripts per EverCtG patient dispensed a PBS Drugs Used in Diabetes script, by 12 month period and site, January 2007 to December 2012 (2007 = 100).........................249

Figure 19: MBS services provided to EverIHI patients, by six month period and site, 2007 to 2012....................................................................................250

Figure 20: Number of EverIHI patients to receive at least one MBS service, by six month period and site, 2007 to 2012.......................................................251

Figure 21: MBS services per EverIHI patient to receive at least one MBS service, by six month period and site, 2007 to 2012.............................................252


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GlossaryAcronyms DescriptionsABCD Audit and Best practice for Chronic DiseaseABS Australian Bureau of StatisticsACCHO Aboriginal Community Controlled Health OrganisationACCO Aboriginal Community Controlled OrganisationACCHS Aboriginal Community Controlled Health ServicesACT Australian Capital TerritoryAHCSA Aboriginal Health Council of South AustraliaAHLO/ALO Aboriginal Hospital Liaison Officer/Aboriginal Liaison OfficerAH&MRC Aboriginal Health and Medical Research CouncilAHPs Allied Health ProvidersAHS Aboriginal health serviceAHW Aboriginal Health WorkerAIDA Australian Indigenous Doctors’ AssociationAMS Aboriginal Medical ServiceAOD Alcohol and Other DrugsATC Anatomical Therapeutic ChemicalATSI Aboriginal and Torres Strait IslanderATSIHP Aboriginal and Torres Strait Islander Health PartnershipATSIOW Aboriginal and Torres Strait Islander Outreach Worker

ASIHPF Aboriginal and Torres Strait Islander Health Performance Framework

CC Care CoordinatorCCSS Care Coordination and Supplementary Services (B3b measure)CD Chronic DiseaseCDM Audits of Chronic Disease ManagementCDSM Chronic Disease Self ManagementCEITC Centre for Excellence in Indigenous Tobacco Control

CPD Indigenous cardiovascular health continuing professional development

CtG Closing the GapDAA Dose administration aid (Webster pack)DoGP Divisions of General PracticeFTE Full time equivalent


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Acronyms DescriptionsGP General PractitionerGPN General Practice NetworkGPNSW General Practice New South WalesHLW Healthy Lifestyle WorkerICDP Indigenous Chronic Disease PackageIHPO Indigenous Health Project OfficerIR Inner RegionalLCC Local Community CampaignLGA Local Government AreaLHD Local Health DistrictLMP Lifestyle Modification ProgramMBS Medicare Benefits SchemeMC Major CityML Medicare LocalMoU Memorandum of Understanding

MSOAP-ICD Medical Specialist Outreach Assistance Program Indigenous Chronic Disease

NACCHO National Aboriginal Community Controlled Health OrganisationNGO Non-Government OrganisationNPS National Prescribing SchemeNRT Nicotine Replacement Therapy

NSFATSH National Strategic Framework for Aboriginal and Torres Strait Islander Health

NSW New South WalesNT Northern TerritoryOATSIH Office for Aboriginal and Torres Strait Islander HealthOR Outer RegionalOSR OATSIH Services ReportOWG Operational Working GroupPBS Pharmaceutical Benefits SchemePCEHR Personally controlled electronic health recordsPHC Primary Health CarePIP Indigenous Health Incentive

Practice Incentive Program Indigenous Health Incentive


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Acronyms DescriptionsQAIHC Queensland Aboriginal and Islander Health Council

QAIHCCPIs Queensland Aboriginal and Islander Health Council Core Performance Indicators

QLD QueenslandRA Remoteness AreaRACGP Royal Australian College of General PractitionersRAP Reconciliation Action PlanRFDS Royal Flying Doctor ServiceRTC Regional Tobacco CoordinatorRTSHLT Regional Tackling Smoking and Healthy Lifestyle TeamSA South AustraliaSA Health South Australia Department of HealthSBO State Based OrganisationSSE Sentinel Sites Evaluation

S100 RAAHSSection 100 Remote Area Aboriginal Health Service. Supply of pharmaceutical benefits to remote area Aboriginal health services under section 100 of the National Health Act 1953

TAS TasmaniaTAW Tobacco Action WorkerUSOAP Urban Specialist Outreach Assistance Program

QUMAX Quality Use of Medicines Maximised in Aboriginal and Torres Strait Islander Peoples Program

VACCHO Victorian Aboriginal Community Controlled OrganisationVIC VictoriaVR Vocationally Registered (GP)WA West AustraliaWAGPN Western Australian General Practice Network


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Key termsKey terms DescriptionsATC1 Anatomical Main Group level of the ATC classification. Medicines

that fall within the anatomical main group of ATC and consist of one letter.

ATC2 Therapeutic Subgroup level of the ATC classification. Medicines that fall within the anatomical main group of ATC and consist of two digits.

Baseline Patient journey and service mapping was undertaken at two points in time: ‘baseline’ and ‘final’. The ‘baseline’ refers to 2009-10. This is the period of time when the ICDP was first being implemented. See Appendix B for a definition of ‘baseline’ relevant to the Sentinel Sites Evaluation.

Final stage Patient journey and service mapping was undertaken at two points in time: ‘baseline’ and ‘final’. The ‘final’ refers to 2012-13. By this stage, the ICDP was in the fourth year of implementation. See Appendix B for a definition of ‘final’ relevant to the Sentinel Sites Evaluation.

CtG scripts Used by service providers and community members to refer to scripts which have been CtG annotated to provide the patient with access to the PBS co-payment relief (B1 ICDP measure).

EverCtG All Aboriginal and Torres Strait Islander people who have ever been dispensed one CtG script at the time when the data were extracted.

NeverCtG People who have ever been dispensed a PBS script and who have never been dispensed a CtG script at the time the data were extracted.

EverIHI All Aboriginal and Torres Strait Islander people who have ever been registered for the PIP Indigenous Health Incentive at the time when the data was extracted. This includes people who registered once but may not have re-registered.

NeverIHI Recipients of Aboriginal and Torres Strait Islander specific Medicare Benefits Schedule services who have never been registered for the PIP Indigenous Health Incentive at the time the data were extracted.

Aboriginal health service

A primary health care practice/Aboriginal Community Controlled Health Service/clinic providing primary care services to a predominantly Aboriginal and Torres Strait Islander population. In this report, AHS may refer to a community controlled health organisation or a different type of entity that primarily provides primary health care services to Aboriginal and Torres Strait Islander people.


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Key terms DescriptionsSentinel Sites Evaluation (SSE)

The Sentinel Sites Evaluation (SSE) comprised five six-monthly cycles of data collection, analysis, interpretation and reporting.Administrative and program data were collated and analysed for 24 Sentinel Sites. The objectives of the SSE were to describe the ICDP implementation, identify and track change and identify the constraints and enablers affecting effective implementation of the ICDP at local level.

Sentinel Site Sentinel Sites are locations identified for the purposes of the SSE data collection. Twenty-four urban, regional and remote sites located across the states/territories were established for the SSE, with different types of sites: tracking, enhanced tracking and case study, distinguished by the depth of data collection at each site. In the context of this report, reference to the ‘Sentinel Sites’ includes only the six sites that were selected to establish the likelihood that findings from the six sites would be consistent with findings from other comparable sites.


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Executive SummaryThis report presents results of the patient journey and service mapping exercises undertaken as part of the Indigenous Chronic Disease Package (ICDP) National Monitoring and Evaluation Project. This is Volume 2 of the Final Report.1

Patient journey and service mapping are among a number of evaluation activities that transcend a measure-by-measure approach to evaluation, and provide insight into the impact of the ICDP on patients and the service system. Patient journey and service mapping take a location-based approach to the evaluation of the ICDP. Evaluation activities were undertaken at six sites, which were selected to include a spread of urban, regional and remote locations across six states and territories. To understand the extent to which the patient journey and service mapping findings are likely to be consistent with findings at other comparable locations KPMG worked with Menzies School of Health Research, the conductors of the Sentinel Sites Evaluation (SSE). Analysis of six comparable sites from the SSE allowed for data triangulation across two independent evaluators, thus increasing the validity of the findings.This involved selecting six of the 24 Sentinel Sites, which were comparable to the six patient journey and service mapping sites discussed in this report (also referred to as the evaluation sites). They are referred to in this report as ‘the Sentinel Sites’ or sites A-F.The findings from the patient journey mapping revealed that, at the selected sites, the ICDP had improved the patient journey for Aboriginal and Torres Strait Islander people with a chronic disease. Improvements to the patient journey have been made in relation to geographical, cultural and financial accessibility, and by building the capacity of individuals to effectively navigate the health care system. The service mapping activity revealed that ICDP contributed to an enhanced service system in the selected sites by funding new Aboriginal and Torres Strait Islander-targeted programs and increasing the capacity (numbers and capabilities) of the Aboriginal and Torres Strait Islander health workforce. The investment in Aboriginal and Torres Strait Islander-targeted programs was consistent with the priorities identified by many Aboriginal and Torres Strait Islander community members. The transition to Medicare Locals (MLs) was a key enabler for the service system enhancements, providing an impetus for increased and more strategic collaboration between the mainstream and AHS sector in most locations and an increased focus on Aboriginal and Torres Strait Islander service delivery within the mainstream sector. The ICDP supported improved organisational capacity, including more culturally appropriate service delivery from mainstream organisations and improved practice systems across the mainstream and AHS sectors, but not across all locations. Consultations with community members indicate that there is still

1 KPMG 2013, Monitoring and Evaluation of the Indigenous Chronic Disease Package: Final Report, prepared for the Australian Government Department of Health, Canberra.


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more work to be done to enhance the cultural capability of some service providers in some locations. Community members identified some ways in which the ICDP was not meeting their expectations; across the country, patients expressed a desire for Aboriginal and Torres Strait Islander-specific face to face smoking cessation supports from the Regional Tackling Smoking and Healthy Lifestyle Teams (RTSHLTs), increased access to some medical aids, such as dose administration aids (DAAs), and extending ICDP funded services such as the CCSS Program and PIP Indigenous Health Incentive measure to under 15 year olds.Findings relevant to patient journey and service mapping at six similar sites (Sentinel Sites) were largely consistent, indicating that the enhancements to the patient journey and service system are likely to have also occurred in other places where the ICDP has been implemented.


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1 Introduction This report presents the patient journey and service mapping undertaken as part of the Indigenous Chronic Disease Package (ICDP) National Monitoring and Evaluation Project. This is Volume 3 of the Final Report.2

The ICDP is the Australian Government’s contribution to the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. The ICDP comprises 14 measures across three outcome areas: tackling chronic disease risk factors, improving chronic disease management and follow up care, and workforce expansion and support.3

Patient journey and service mapping are among a number of evaluation activities that transcend a measure-by-measure approach to evaluation, and provide insight into the impact of the ICDP on patients and the service system.Patient journey and service mapping take a location-based approach to the evaluation of the ICDP. Evaluation activities were undertaken at six sites, which were selected to include a spread of urban, regional and remote locations across six states and territories. It is important to note that not all measures had been implemented, or were present to the same extent, in each of the six sites. Some measures, such as the Regional Tackling Smoking Health Lifestyle Teams and attracting more people to work in Aboriginal and Torres Strait Islander health, have national coverage by design. Other broad reaching measures, such as PIP Indigenous Health Incentive and the PBS Co-payment were present in all sites. The presence of workforce-based measures such as CCSS and the SOAP measures was more variable.

1.1 Purpose The purpose of patient journey mapping is to identify the impact of the ICDP on access to health services relevant to chronic disease prevention and management for Aboriginal and Torres Strait Islander people. Patient journey mapping describes and discusses the experience of community members and service providers based on consultations, and presents analysis of the impact of the ICDP on the patient journey based on secondary data sources. The purpose of service mapping is to assess the impacts of the ICDP on the health service system, such as impacts to system capacity and service coordination. Service mapping describes and discusses the characteristics of the local service system and community members’ and service providers’ experiences of the service system, and again presents the results of analysis of relevant secondary data sources.The concepts of service system capacity and patient experience are closely linked, and the information, analysis and findings are presented in an integrated way. A conceptual framework is used to interpret the findings as relevant to both patient journey mapping and service mapping (see chapter 2). 2 ibid.3 Please see Volume One of this report for a detailed description of each of the 14 measures.


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1.2 Overview of approachThis section contains an overview of the approach taken; Appendix C: Analysis provides more detailed information about the methodology, including a discussion of limitations.

1.2.1 Site selectionSix sites, each in a different state or territory, were selected for patient journey and service mapping. The sites selected provide some coverage across urban, regional and remote communities where ICDP investment was present. The sites selected included two major city (MC) sites, one inner regional (IR), two outer regional (OR) sites, and one remote site.4 The six sites selected for this evaluation activity are referred to throughout this report as ‘the sites’, ‘the evaluation sites’ or as sites 1-6. For more information on the sites, see Appendix A: Patient journey mapping and service mapping site selection.

1.2.2 Data collection timingData relevant to two points in time was collected and analysed: 2009-10, referred to throughout this report as the baseline patient journey

map and baseline service map or ‘at baseline’. This is the period of time when the ICDP was first being implemented.5

2012-13, referred to throughout this report as the final patient journey map and service map, or ‘at the final stage’. At this point in time, most ICDP measures had been in place for around two years in most locations.

1.2.3 Conceptual frameworkA conceptual framework was developed to allow a structured approach to the presentation of information and analysis of the service system and the patient experience. The conceptual framework defines three inter-related domains and characteristics of the service system and patient journey: system capacity; access; and service coordination. The conceptual framework is described in detail in Chapter 2.

1.2.4 Methods of data collectionA number of methods were used to collect qualitative and quantitative data: Research and a literature review were conducted to inform development of a

national health system map, which forms the background for the site level service mapping, and the development of the conceptual framework.

4 Classified according to the Australian Standard Geographical Classification (ASGC) remoteness structure. The sites are sometimes referred to as urban (Major City), regional and remote within this report. 5 Chapter 1.2.2 discusses some issues associated with data collection relevant to 2009-10 and use of the term ‘baseline’.


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Stakeholder consultations were conducted during site visits, and undertaken with health service providers and Aboriginal and Torres Strait Islander community members. In total, 120 community members were engaged through 17 focus groups focusing specifically on the patient journey and service system. A broad range of community members and service providers were also engaged in more general evaluation consultations during which concepts relevant to patient journey and service systems were discussed.

An organisational survey was administered to health service providers and organisational representatives during site visits. This was administered to 12 stakeholders across the six sites.

Analysis of site-level secondary data sources was undertaken, including Medicare Benefits Schedule (MBS) data, Pharmaceutical Benefits Scheme (PBS) data, Practice Incentive Program (PIP) Indigenous Health Incentive data and Office of Aboriginal and Torres Strait Islander Health (OATSIH) Services Report (OSR) data.

Analysis of other publicly available data and documentation was undertaken, including statistics from the Australian Bureau of Statistics (ABS) and publically available information relating to the health system at each of the sites.

1.2.5 AnalysisData was analysed at a number of different levels: At the site level, data analysis focused on gaining insights into the typical

patient experiences and the Aboriginal and Torres Strait Islander health service system at each site.

By remoteness, data analysis focused on commonalities and differences between urban, regional and remote sites.

Specific focus areas across the sites, with data analysis focusing on:- at ‘the baseline’, early presence of indicators of change and expected

impacts of the ICDP; and - At ‘final stage’, identification of changes that have occurred, and

comparison with the findings of the Sentinel Sites Evaluation (SSE) of the ICDP.6

1.2.6 Comparison with SSETo understand the extent to which the patient journey and service mapping findings are likely to be consistent with findings at other comparable locations KPMG worked with Menzies School of Health Research, the conductors of the SSE. Six of the 24 Sentinel Sites were selected and Menzies School of Health Research evaluators reviewed the comprehensive data collected in the course of the SSE and undertook analysis comparable to that undertaken for this patient journey and service mapping activity. Comparison of the findings from the evaluation sites and the Sentinel Sites was then undertaken to inform a view about the extent to which findings from the evaluation sites are likely to be 6 See the glossary for a description of the Sentinel Sites Evaluation.


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consistent with findings at other comparable locations. The six Sentinel Sites selected are referred to throughout this report as ‘the Sentinel Sites’ or sites A-F; sites A and B are urban sites; C and D are regional sites and E and F are remote sites. .

1.3 Structure of this documentThis document commences with an introduction and a discussion of the conceptual framework used to guide presentation of information and analysis of the service system and the patient experience. This is followed by presentation of the patient journey and service maps, and associated discussion, for each of the six sites (chapter 3). Overall analysis of the patient journey and service mapping evaluation activities is then provided in chapters Error: Reference source not found and 5.Appendices include presentation of the methodology, a summary of the work undertaken in conjunction with Menzies School of Health Research and the national service map, which forms the background for the service mapping at each of the six sites.


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2 The conceptual framework The conceptual framework provides a structured approach to presentation of information and analysis of the service system and the patient experience. The framework defines domains and characteristics of the service system and patient journey. The three interrelated domains of the framework are: system capacity; access; and service coordination. To achieve reductions in the incidence of preventable chronic disease and to improve outcomes for Aboriginal and Torres Strait Islander people with chronic disease, improvements across system capacity, access and service coordination are all desirable.

2.1 System capacity System capacity refers to the capacity of the system to meet patient needs and enhance the patient journey. The capacity of the system is influenced by the infrastructure, services and resources available to deliver quality chronic disease prevention and management, in accordance with patient and community needs. Table 1 describes a set of characteristics and associated indicators, which can be used to assess the impact of the ICDP on system capacity at individual sites.


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Table 1: System capacity characteristics and indicators. Characteristics IndicatorsThere is appropriate infrastructure (facilities and equipment) for delivery of health care services.

Perceptions of service providers and community members around the suitability of infrastructure.Services are ‘ICDP ready’ (i.e., have capacity to take up funding opportunities and implement ICDP measures).

The system has a sufficient health workforce to meet community needs.

Perceptions of service providers and community members around the capacity and sustainability of the health workforce.Funded ICDP workers are recruited.Services are ICDP ready.Through the ICDP Aboriginal and Torres Strait Islander staff are placed in the mainstream sector.

Services reflect the needs of patients and the community, and may be informed by needs assessment.

The extent to which services meet community needs.Perceptions of service providers and community members.The ICDP adds new service(s) that are needed or in demand.

Services have practice management and clinical information systems with a focus on good practice patient care and quality improvement.

The extent to which services have appropriate systems in place.Perceptions of service providers.Services are ICDP ready.

Services have strong leadership and organisational commitment to addressing the health needs of Aboriginal and Torres Strait Islander patients.

Senior involvement in and support for the ICDP and other Aboriginal and Torres Strait Islander heath focused programs.Perceptions of ICDP workers and other service providers.Services are receptive to the ICDP.Services are ICDP ready.Services demonstrate cultural competency.

2.2 Access The National Indigenous Reform Agreement refers to ‘Access’ as a service delivery principle for programs and services for Aboriginal and Torres Strait Islander people, stating ‘programs and services should be physically and culturally accessible to Indigenous people recognising the diversity of urban, regional and remote needs.’7 Access, then, encompasses availability, accessibility and appropriateness of services, which in this case mean access to comprehensive preventive care, primary health care and follow up care.

7 Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) n.d., C losing the Gap: National Indigenous Reform Agreement (webpage), FaHCSIA website, accessed July 2012, <http://www.fahcsia.gov.au/our-responsibilities/indigenous-australians/programs-services/closing-the-gap/closing-the-gap-national-indigenous-reform-agreement>.


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Lack of access to services is well recognised as a problem in rural and remote areas, but can also be experienced in urban communities.8 Physical access can be determined by the number of available services, service proximity, availability of transportation, and hours of service delivery. Factors such as affordability of services and health literacy (i.e., the capacity to use health information, including how and when to access services) can also play an important role for Aboriginal and Torres Strait Islander people. Systems, organisations and practitioners must take into consideration the values, beliefs and practices of clients, and adapt services to address the specific socio-cultural and language needs of individual users, in order to ensure culturally competent services. Cultural appropriateness is supported not only through the behaviour of health service providers but also through organisations and systems. Characteristics of culturally appropriate services may include staff who have cultural ties to the client community, cultural training and immersion for staff, communication that is tailored to the patient, awareness of cultural interpretations of illness and traditional remedies, inclusion of family members in appointments and decision making, and consideration of patient needs in service monitoring and improvement efforts. From the patient perspective, access to culturally appropriate services means that patients experience positive, respectful and trusting relationships in the service setting, and that they have the support they need to communicate with providers and make decisions. Supports may be inclusion of family members, access to Aboriginal and Torres Strait Islander liaison officers or access to translators.9 Table 2 describes a set of characteristics and associated indicators, which can be used to assess the impact of the ICDP on access at individual sites.

8 Andrews B., Simmons P., Long I. & Wilson R. 2002, ‘Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales’, Australian Journal of Rural Health, vol. 10, no. 4, pp. 196-201.Scrimgeour M & Scrimgeour D. 2008, ‘Health Care Access for Aboriginal and Torres Strait Islander People Living in Urban Areas, and Related Research Issues: A Review of the Literature', CAPER Discussion Paper Series: No. 5, CAPER: Casuarina.9 Ngo-Metzger Q, Telfair J, Sorkin D, Weidmer B, Weech-Maldonado R, Hurtado M & Hays R 2006, Cultural Competency and Quality of Care: Obtaining the Patient’s Perspective, pub no. 963, The Commonwealth Fund, accessed July 2012, <http://www.commonwealthfund.org/usr_doc/Ngo-Metzger_cultcompqualitycareobtainpatientperspect_963.pdf>.


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Table 2: Access characteristics and indicators.Characteristics IndicatorsServices are physically accessible to patients, or support physical access, e.g., through provision of transport or outreach.

The extent to which services are geographically accessible for all people in the region.Perceptions of service providers and community members.The ICDP addresses relevant commonly identified barrier(s) to accessing services.ICDP activity is in place in key organisations within the community.ICDP activity is in place across multiple organisations, including within both mainstream and Aboriginal health service (AHS) sectors.

Services are financially accessible to patients.

Options exist within the system which allow people to choose health care which is both suitable and affordable (e.g. access to bulkbilled GP services, public specialist clinics).People can and do utilise existing financial supports to enhance their access.

Services target, and are tailored to, multiple patient groups.

The extent to which services target multiple patient groups.Perceptions of service providers and community members.The ICDP addresses relevant commonly identified barrier(s) to accessing services.ICDP activity is in place in key organisations within the community.ICDP activity is in place across multiple organisations, including within both mainstream and AHS sectors.

There are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments and decision making.

Examples of mechanisms to support cultural appropriate care within services.Services demonstrate cultural competency.The ICDP addresses relevant commonly identified barrier(s) to accessing services.

Services take steps to ensure a culturally appropriate environment for patients.

Services demonstrate cultural competency.Perceptions of service providers and community members.The ICDP addresses relevant commonly identified barrier(s) to accessing services.

There is receptivity to change within organisations to make services more culturally appropriate for patients.

ICDP workers are recruited, ICDP measures are implemented (e.g., practices register for PIP Indigenous Health Incentive).Workers have undertaken cultural awareness training.The ICDP addresses relevant commonly identified barrier(s) to accessing services.Services are receptive to the ICDP.

The health workforce has cultural ties to the patient group.

Evidence of the ICDP and other workers having ties to the local community.

Cultural awareness training Workers have undertaken cultural awareness training.


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Characteristics Indicatorsand immersion is available to the health workforce.

The ICDP addresses relevant commonly identified barrier(s) to accessing services.Services are receptive to the ICDP.

2.3 Service coordination ‘Service coordination aims to place consumers at the centre of service delivery - ensuring that they have access to the services they need, opportunities for early intervention and health promotion and improved health outcomes. The practice of service coordination particularly supports more effective ways of working with people with complex and multiple needs [such as for] integrated chronic disease management.’10 Service coordination is influenced by the interactions and relationships between services, the mechanisms through which patient care is managed, the complementarity of the services within the system, and a focus on patient-centred planning and care. From a patient perspective, service coordination is the experience of timely, seamless access to the healthcare services that they need. Good service coordination is characterised by effective networking, cooperation and collaboration between services that support chronic disease prevention and management. Practices that support service coordination may be informal (e.g., referral protocols, service directories, cross-agency awareness training) or formal (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, shared information systems and joint planning).11 In the context of service delivery to Aboriginal and Torres Strait Islander people, service coordination may be improved by staff who are also Aboriginal and Torres Strait Islander and/or have credibility, existing contacts, local knowledge and trusting relationships within the community.12

10 Department of Health Victoria 2012, Service Coordination (webpage), Primary Care Partnerships section, Department of Health Victoria website, viewed July 2012, <http://www.health.vic.gov.au/pcps/coordination/>.11 Stewart J., Lohoar S., Higgins D. 2011, Effective practices for service delivery coordination in Indigenous communities, Resource Sheet 8, Closing the Gap Clearinghouse, Canberra; Australian Institute of Health and Welfare and Melbourne, Australian Institute of Family Studies.12 ibid.


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Table 3 describes a set of characteristics and associated indicators, which can be used to assess the impact of the ICDP on service coordination at individual sites.

Table 3: Service coordination characteristics and indicators.Characteristics IndicatorsNetworking, cooperation and information sharing between services relating to patient care is occurring.

There are relationships between services funded for the ICDP, including across mainstream and AHS sectors.There are relationships between other service providers.Service provider perceptions.

There is a focus on patient-centred planning and care delivery involving multiple providers.

Community member perceptions.

Informal mechanisms or practices that support service coordination and patient centres planning and care delivery (e.g., referral protocols, service directories, cross-agency awareness training) are in place.

Evidence of informal mechanisms or practices that support service coordination and patient centred planning and care delivery.There are relationships between services funded for the ICDP, including across mainstream and AHS sectors.Service provider perceptions.

Formal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, and shared information systems and joint planning) are in place.

Evidence of formal mechanisms or practices that support service coordination and patient centred planning and care delivery.Service provider perceptions.

Services within the system are complementary and there is no duplication.

Identification of duplication of services (which is not necessary to meet community needs).Service provider and community member perceptions.


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3 Site specific patient journey and service mapping The following chapters present information about the patient journey and service system at baseline and then describes the impact the ICDP had on the patient journey and service system at each of the six sites. The baseline information includes a description and visual representation of the service system and patient journey map at baseline, a pre-ICDP assessment of the site against the conceptual framework and discussion of what changes seemed likely based on what was known about ICDP investment and activity at the time.For each site, the impact of ICDP, as observable at the final stage, is presented and discussed. These sections include information about actual ICDP investment and activity at each site, summary data relating to changes in indicators of interest, updated patient journey and service maps and an assessment of the site against the conceptual framework to identify changes at the site since baseline.

3.1 Site one (Major City)3.1.1 Site one at baseline The site is an outer-urban area of a large capital city and is home to one of the largest urban Aboriginal and Torres Strait Islander populations in Australia. The Aboriginal and Torres Strait Islander community is dispersed across a large area, however many community members live in and around two large central suburbs that are around 40 kilometres from the city centre. There were a broad range of facilities available within the region at baseline. They included hospitals, community health centres, many general practices, specialists and allied health providers, and a large AHS. Barriers around the cost of primary and secondary health care13 were identified, as well as waiting times for free services, for example bulk billing GPs at the AHS. At baseline, this area was not considered a district of workforce shortage for general practice. Table 4 provides summary statistics for site one, covering the local population profile, participation in the PIP Indigenous Health Incentive and conduct of Health Assessments.

13 Primary care refers to the first level of care or the entry point to the health care system and usually refers to GPs and allied health care professionals. Secondary care generally refers to services provided by medical specialists and other health professionals who generally do not have first contact with patients.


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Table 4: Summary of population, engagement in PIP Indigenous Health Incentive and Health Assessments in 2009-10.14 Indicator StatisticEstimated Resident Population (2011 Census) 810,734Aboriginal/Torres Strait Islander population (2011 Census) 11,503Proportion of Population identifying as Aboriginal and Torres Strait Islander

1.4%

Patients ever registered for PIP Indigenous Health Incentive at June 2011

1496

Proportion of Aboriginal and Torres Strait Islander residents ever registered for PIP Indigenous Health Incentive at June 2011

13%

Number of Aboriginal and Torres Strait Islander Health assessments by site in 2009-10

97

Site one includes two hubs, four hospitals, many GPs and pharmacies, an AHS which provides outreach, two after-hours GP services and four community health centres. Prior to the implementation of the ICDP no Divisions of General Practice (DoGP) or Medicare Local had an Aboriginal and Torres Strait Islander health program and no general practices were found to have Aboriginal and Torres Strait Islander staff.

General practice system A broad range of chronic disease related services were available through the four hospitals at baseline, such as cardiac, renal, chronic care services, allied health, dialysis, oncology, step down units and palliative care. Each of the hospitals had funding for an Aboriginal Hospital Liaison Officer (AHLO). Community health centres operated out of each of the hospitals providing primary health care such as general practice (GP) services, nursing and allied health.There were many GPs working in a large number of private, general practices. It is likely the practice management arrangements across the region were variable at baseline, given the large number of private primary health care practices in the region. The use of data for performance management and evaluation by the Medicare Local and the AHS suggests a focus on performance and patient outcomes. The Medicare Local was collecting patient and service data at baseline, including: demographic data; living arrangements; Aboriginal and/or Torres Strait Islander status/ethnic background; service data (e.g., number of clients receiving service and occasions of service); and referral data (e.g., new referrals). Data was not being stored electronically. Data was being used primarily for reporting, performance management and measuring outcomes. It was also being used to some extent to inform internal governance/quality improvement, needs assessment and service planning. Specialist services were accessible in both secondary and tertiary settings, through a range of private specialist consulting rooms; visiting specialists 14 Based on ABS population estimates and Medicare data provided by the former Department of Health and Ageing.


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providing services from local primary health care practices; and hospital based specialist services.

Aboriginal and Torres Strait Islander health services The site is home to a large AHS, which provides primary health care, health promotion, child and family health, social and emotional wellbeing and dental, as well as a broad range of chronic disease services. In 2009-10, the AHS had a total of 66 FTE positions on staff; five of which were doctors, 14 were AHWs and two of which were specialists or Allied Health Professionals (AHPs). These were available to patients free of charge. There was also one visiting specialist working out of the AHS but not paid by the AHS. A total of 18,743 episodes of care were provided in 2009-10; at least 10,772 of which were to Aboriginal and Torres Strait Islander patients. There were 27,937 client contacts over the same period, the majority of which were with doctors (6,569) and nurses (8,537) followed by AHWs (3,686) and specialists or AHPs (418).15 Some outreach services relevant to chronic disease management were being provided by the AHS including home medication reviews (HMRs). The AHS indicated a commitment to continuous quality improvement, and community members noted during focus groups that the AHS had recently implemented a patient booking system as a system improvement. The AHS was collecting patient and service data at baseline. The AHS was using a patient information recall system, which also records clinical data. The AHS reported that patient data, although electronic, was poor in quality and not very useful. An indication of this might be that, at baseline, there were still 1,744 clients (representing around a third) whose Aboriginal and Torres Strait Islander status was not recorded. Outside of the AHS, an Aboriginal and Torres Strait Islander mobile health van was operating around the area primarily from community organisations. Health Assessments and other primary health care services were available from this van at baseline.Table 5 below provides a summary of chronic disease related services provided by the AHS in site one in 2009-10.

15 Aboriginal and Torres Strait Islander health services report 2009–10: OATSIH Services Report. Provided to KPMG by the former Department of Health and Ageing with the permission of the relevant organisation.


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Table 5: Summary of chronic disease related services provided by the AHS in site one in 2009-10.16

Chronic disease related services provided by the AHS in site one in 2009-10

Yes/No

Management of diabetes YesManagement of cardiovascular disease YesManagement of other chronic illness YesService maintains health registers YesShared care arrangements for management of chronic disease

Yes

Chronic disease management groups YesTobacco use treatment/prevention groups Yes

AccessOne of the hospitals in the region was operating an Aboriginal Health Unit, which functioned to support collaboration between the Area Health Service and NGOs around Aboriginal and Torres Strait Islander Health. To enhance the cultural appropriateness of those services, four AHLOs positions have been funded within the hospitals. These staff are often community members, who understand local contexts/interpretations of illness and can act as cultural brokers between patients and the health system. Their role is to ensure culturally appropriate care is provided to Aboriginal and Torres Strait Islander people who require hospital based health careEach hospital offered limited patient transport and accommodation, which was allocated based on need and with associated costs. One hospital had a dialysis patient transport service. The hospitals were also participating in the Pathways Home Project, providing transition care and discharge packs (none of these services were Aboriginal and Torres Strait Islander specific). Available GP services included at least two afterhours services and locum services. During baseline consultations, the newly formed Medicare Local was planning to establish an afterhours GP program in the future. Community and Non-Government Organisations (NGOs) were running some transport services in the region, for example, transport to and from health appointments for some community members, including Aboriginal and Torres Strait Islander community members. The AHS was open weekdays from 9am-5pm; however, community consultations suggested there were long wait times for GP services. No afterhours episodes of care were recorded in 2009-10. The AHS also provided patient transport on an ad-hoc/needs basis for patients. The AHS had a number of local Aboriginal and Torres Strait Islander staff, including 14 (FTE) Aboriginal Health Workers to provide culturally appropriate care. AHS staff report that they only refer to mainstream providers that are considered to provide culturally appropriate care. 16 Based on information gathered during site visits and research.


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Community members consulted generally perceived general practices to be culturally appropriate; around half of the people engaged through focus groups used a general practice rather than the local AHS due to convenience, or preference.

Service coordinationCommunity consultations suggest the local Aboriginal and Torres Strait Islander services were well connected, in particular with other Aboriginal and Torres Strait Islander services, but also with general practices. AHS staff commented that they were making regular referrals to a range of support services in the community for chronic disease self management. Staff at the AHS reported good relationships with the major outer-city health service, and with some local primary health care services (including pharmacists). The Medicare Local and the AHS had worked together participating in cultural awareness training, and sharing information about common clients via informal processes only. The Medicare Local had also engaged informally (e.g., referrals, information sharing) with the Aboriginal and Torres Strait Islander drop in centre. Collaborative service promotion was being undertaken, and both Aboriginal and Torres Strait Islander and mainstream local services were supporting cross promotion through making brochures and posters available in their centres, and information available on their websites. Overall, service providers reported that the service system was effective in key areas of service coordination – with the Medicare Local providing 10/10 ratings for the system’s performance across all of the areas considered to influence service system effectiveness, and the AHS providing 8/10 ratings.17

Patient experienceAt this site, patients had access to a variety of services– both mainstream and Aboriginal and Torres Strait Islander, giving people options in terms of the types of services they accessed, and the way they accessed these services. Barriers existed however in terms of the costs of health care, and transport to and from appointments, impacting on engagement with health services.

PreventionThe key prevention issues identified by community members were: Unhealthy habits (smoking, physical inactivity, unhealthy food) are the

‘norm’. Lack of motivation to change to healthy lifestyles. Few (known or accessible) opportunities for sport and exercise.Smoking, unhealthy eating and physical inactivity are big problems in the community; unhealthy lifestyle behaviours often start early and become the norm. Fruit and vegetables, and other healthy food options are available at many outlets, and there is variety and choice.

17 Where 10 is very effective service coordination and 0 is ineffective service coordination. Based on information collected during site visits.


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‘Lots of people are smoking, the old ones and the young ones.’18

‘There are lots of places you can buy healthy food, but people eat takeaway all the time.’19

Community members are aware of many of the preventive health care programs and activities available within the region. There is a feeling that if people want to access these programs they can, but they have to seek them out which requires them to be motivated, and well connected with local organisations.

‘For quitting smoking? There is one program in the men’s shed [at host organisation].‘20

Lack of motivation can be a real barrier to access to preventive services because many people only access health care if they really need it. For example, many people say they want to quit smoking, but many still smoke. Community members report that one of the reasons people are not physically active is that opportunities to participate in sport are limited. According to community members, for young people sport is only available through school, and for older people opportunities to participate in sport are very limited. Community members report that most people do not exercise regularly. Given the location of this site, it is likely that many opportunities to participate in sport and exercise do exist, but perhaps Aboriginal and Torres Strait Islander people are not aware or do not feel able to take up these opportunities. The popularity of electronic forms of entertainment (i.e., video games) is seen to have a negative impact on participation in physical activity.

‘No one out on the street anymore like there used to be. No one playing hopscotch like there used to be.‘21

Community members in the region use many different primary health care services – both local mainstream providers and the AHS. Access to primary health care is usually for an existing health condition or need (access to primary health care is discussed further under diagnosis and treatment below). Being engaged with a primary health care provider is seen to be beneficial because many local providers offer, or can make referrals to preventive health programs and activities. When people do engage with preventive health care they can usually receive the kind of health and support they need; whether this is from a general practice or an Aboriginal and Torres Strait Islander service.

Diagnosis and treatment The key diagnosis and treatment issues identified by community members were: Costs associated with health care, and transport to health care, which impacts

on access to health care. Poor knowledge of and access to allied health care. AHS has insufficient capacity to meet demand.

18 Community member, site one.19 ibid.20 ibid.21 ibid.


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Reluctance amongst some community members to access health care due to fear.

Community members who use the AHS can access bulk billed appointments, low cost pharmaceuticals and be seen by Aboriginal staff. Community members commented that travelling to the AHS, however, is difficult without private transport, and there are long waiting times for appointments – between 1-4 hours depending on the time of day patients arrive, and whether they have made a booking in advance. In 2009-10 the AHS reported 5,266 total clients, at least 3,303 of which were Aboriginal and/or Torres Strait Islander, representing just over a quarter of the total Aboriginal and Torres Strait Islander population in the area. For some patients accessing Aboriginal and Torres Strait Islander specific services is so important, that when they cannot get into the local AHS, they travel into the city to access another AHS. For others, although there is a perception that the AHS provides culturally appropriate care, the challenges relating to wait times, access outweigh the benefits, and community members prefer to access general practices. Community members who use general practices generally have positive experiences, and there is a common perception that these services provide culturally appropriate care. The services people have access to though their chosen GP, and the costs associated with appointments, however, can vary. Only some general practices bulk bill, which is considered a barrier by many community members. Generally, people choose general practices because they know them, feel comfortable with them, or in some cases prefer them to the AHS GPs. Again, general practices can be difficult to access without private transport.

‘A doctor that was in [rural town] is now in [this community]. I still see the same Doctor that used to be in [rural town].’ 22

When people access primary health care it is usually because they are sick, they need medicines, they have chronic disease, or they want a health check. However, many people do not want to get health checks at all. Others do not want to go to the doctor for a health check, but are willing to have one via the mobile van (an Aboriginal-specific service) that visits local community organisations periodically. This is because other people are getting a health check at the same time, and the health checks are provided in a familiar location.

‘If you get a health check, you might find something.’ 23

‘People worry about dying – they think ‘I might not come home [from the doctor] if I go.’24

Many people do not go to the doctor when they are sick. For younger people who are not sick at all or not very sick, it helps if others encourage them to go to the doctor, or if someone they know has already had a health check. Community members get their medications through local pharmacies and the AHS. Access to reduced price medications at the AHS is seen as a facilitator and

22 ibid.23 ibid.24 ibid.


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influences people to access primary health care there. Community members report that many people are on multiple medications, which can be unaffordable – the cost of medications is seen as a significant barrier to accessing health care for chronic disease. People often do not take the medication they need for their chronic disease because they cannot afford it, or because they do not want to go to the doctor for a prescription. Sometimes community members share medications when they have similar chronic diseases.

‘Sometimes I didn’t take blood pressure tablets because I didn’t have enough money.’25

When some people are first diagnosed with a chronic disease, they do not necessarily know what has to be done to manage their condition. Nonetheless, community members reported that they generally know where to go for help. There is variable understanding of chronic disease management services within the region. For example, community members have mixed understanding of the allied health services available in the community and how they can access them. Conversely, community members have a good understanding of specialist services available in the region through hospitals and visiting services to the AHS. Most people understand where they would need to go if they required a specialist service for their chronic disease.

‘The doctors [at the AHS] can provide information about how to manage your chronic disease.‘26

‘People on dialysis go to [local hospital].’27

The cost of accessing private health care (e.g., AHPs, specialists) is seen as a significant barrier, and free services through the AHS are in high demand. Even when people receive financial support (e.g., from the government), many people do not have the required up-front payment, which can be up to $400. This means that people may not access specialist care required for chronic disease management. While the free specialist and AHP services provided from the AHS are seen as a facilitator, there were only two FTE permanent specialists/AHPs at the AHS at baseline and one visiting specialist. Client contacts with these staff were only 1.5 percent of all client contacts in 2009-10.Similar to the above, some people are also scared to see a medical specialist because of the implications and potential consequences (e.g., costs, follow up required, may find a health issue). Again, access to private transport is usually required to attend specialist appointments. In some cases, people have to travel to the city to access specific specialist care. Travelling for dialysis is similarly a significant issue for many people because of the frequency of care required. Table 6 shows professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.



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Table 6: Professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.28

Professional Attendances 2009/10

Pathology Services 2009/10

EverIHI patients (ever PIP IHI June 2011)

Professional attendances per EverIHI patient

Pathology per EverIHI patient

14,313 7,651 1,496 9.6 5.1

Ongoing treatment and supportThe key ongoing treatment and support issues identified by community members were: Social determinants of health (i.e., financial situation, drug and alcohol use,

other priorities) impacting ongoing access to health care. Variable support from primary health care services for ongoing treatment and

support.Community members know that they can go to the GP (AHS or mainstream) for help and support once they have been diagnosed with a chronic disease. However, community members commented that some GPs are more supportive than others when it comes to follow up care.

‘Doctors ring if I miss my appointments.’29

There are also many community support services known to and accessed by community members, which provide transport assistance, social and emotional support, and linkages with other services, such as Centrelink. Often people hear about these services through local Aboriginal and Torres Strait Islander services.

‘Housing and Centrelink people come to the men’s shed – it makes it easier to get the right information.’30

The issues experienced relating to transport and costs mean there are challenges associated with accessing ongoing specialist care for some people. If people have to travel to access services, they are less likely to maintain engagement with health care. Maintaining health care can be difficult with a range of broader lifestyle factors affecting peoples’ ability to manage their chronic diseases.

‘I’ve got breast cancer. But I don’t take medicine cos I smoke the Yandi [marijuana] instead.’ 31

Baseline assessment Table 77 below draws together the information presented above about site one at the final stage. Against conceptual framework domain characteristics, this table provides the rating32 the evaluators gave the site at baseline.

28 Based on Medicare data provided by the Australian Government Department of Health. 29 Community member, site one.30 ibid.31 ibid.


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Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.


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Table 7: Assessment of site one against the conceptual framework.Domains Characteristics Rating AssessmentSystem capacity

There is appropriate infrastructure (facilities and equipment) for delivery of health care services.

2 There was adequate physical infrastructure in both AHS and mainstream sectors including purpose built facilities. No gaps were identified.


2 The site had a large and well established AHS and many mainstream providers. Significant ICDP investment was planned at baseline.

Services reflect the needs of patients and the community (and may be informed by needs assessment).

1 There were some gaps in the service system – namely Aboriginal and Torres Strait Islander specific programs and transport, which the ICDP was expected to address.


1 There had been a recent move to an electronic practice management system within the AHS and both the AHS and DoGP appeared focused on monitoring and evaluation. However, the AHS had a clinical information system that was not considered useful. Patient follow up was regularly undertaken by AHS staff and AHLOs.


2 Both the AHS and DoGP appeared committed to Aboriginal and Torres Strait Islander health based on the perspectives of staff.

Access Services are geographically accessible to patients, or support physical access e.g., through provision of transport or outreach.

1 The area of the site is large but has a lot of public transport around the area, and to and from the city. Many patients, however, did not have access to private transport and the AHS transport service could not meet demand.


1 Several examples of affordable health care options were identified (e.g. bulkbilling GPs, free specialist and AHP service through the AHS), however these may be insufficient to meet demand or financial assistance may be insufficient for some patients (e.g. where a significant upfront payment is required).

Services target (and are tailored to) multiple patient groups.

1 Both the DoGP and AHS targeted broad target groups including special needs groups such as people with chronic disease. Patients reported a need for more Aboriginal and Torres Strait Islander specific services.

40KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed

in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards Legislation.


June 2014

Domains Characteristics Rating AssessmentThere are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments and decision making.

2 The majority of general practices were reported to be culturally competent, and the AHS provided care coordination and AHLO services.

Services take steps to ensure a culturally appropriate environment for patients AND/OR…

2 There were examples of this provided by patients such as relevant posters, signs and Aboriginal and Torres Strait Islander artwork within services.


2 General practices were receptive to Aboriginal and Torres Strait Islander health initiatives at baseline, and to making the changes associated with these, e.g., implementing identification protocols.

The health workforce has cultural ties to the patient group AND/OR…

2 There were local Aboriginal and Torres Strait Islander people working at the AHS and local hospitals.

There is cultural awareness training and immersion is available to the health workforce.

1 The AHS and DoGP staff had done some cultural awareness training, but there was no information about whether GPs had completed this, at baseline.

Service coordination

Networking, cooperation and information sharing between services relating to patient care is occurring.

1 Largely informal through referrals, information sharing, collaborative promotion.

There is a focus on patient centred planning and/or care delivery involving multiple providers.

1 There appeared to be some engagement between services around patient care but this depended on the individual worker, and which services the patient was accessing. Patients reported mixed views about continuity of care and care coordination.

Informal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., referral protocols, service directories, cross-agency awareness training) are in place.

1 Yes, as above.

Formal mechanisms or practices that support service coordination and patient

0 None reported at baseline.




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Domains Characteristics Rating Assessmentcentred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, and shared information systems and joint planning) are in place.Services within the system are complementary and there is no duplication.

2 There were many services, but also very high demand for services from the population. Thus, the risk of unnecessary duplication was limited.




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Changes expected to occur as a result of the ICDP at baselineTwo organisations at this site had ICDP funding at baseline; the DoGP was funded for ATSIOWs, a Care Coordinator and IHPO and an AHS was funded for a RTSHLT. At baseline, it was reasonable to expect that the following changes would occur as a result of the ICDP: The work of the RTSHLT was expected to complement existing allied health

services being provided by the AHS at baseline, and existing AHS smoking cessation programs. The team represented a new type of Aboriginal and Torres Strait Islander-specific healthy lifestyle services.

The PBS Co-payment measure was expected to assist a large proportion of the Aboriginal and Torres Strait Islander population by reducing financial barriers to accessing medicines. No pharmaceutical programs (e.g., S100 RAAHS and QUMAX) were available through the AHS at these sites at baseline.

The work of the IHPO was expected to increase uptake of the PIP Indigenous Health Incentive and PBS co-payment measures. At baseline, the need to work with GP practices to improve cultural competency was considered low in this site.

There was no USOAP funding allocated at the time of baseline consultations, but the SS funds under the CCSS measure were expected to address some of the significant financial barriers associated with accessing and paying for specialist appointments.

The work of the ATSIOWs was expected to address transport difficulties for patients; supplementing the existing transport service provided by the AHS, which was unable to meet demand prior to implementation of the ICDP.

3.1.2 Site one at final At the final stage, the key characteristics of the site remained much the same, that is: there was a large and geographically dispersed Aboriginal and Torres Strait

Islander population; there were broad range of services available at the site, including an AHS

which was considered a ‘central’ service in the region; the level of cultural appropriateness within general practices was variable;

while many were considered largely culturally appropriate, others were not considered culturally appropriate at all; and

the area was not considered a district of workforce shortage for general practice.

At baseline, the main ICDP-funded mainstream organisation was a DoGP. By the final stage, the DoGP had become a Medicare Local as it was funded in the first tranche of funding and was well established by 2012-13.


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ICDP workforce investment and activity at site oneAt site one 12.5 FTE ICDP workers were allocated across the AHS and the Medicare Local by final stage, as Table 8 below shows. This large investment reflects the significant Aboriginal and Torres Strait Islander population in the region.

Table 8: ICDP workforce allocation (FTE) within site one 2012-13 (various dates).33

Position AHS

ML Total Allocation

Care Coordinator (CC) 0 0.50

0.50

Indigenous Health Project Officer (IHPO)

0 1.75

1.75

Outreach Worker (ATSIOW) 1 2.00

3.00

Regional Tobacco Coordinator (RTC)

1 0.00

1.00

Tobacco Action Worker (TAW) 3 0.00

3.00

Healthy Lifestyle Worker (HLW) 2 0.00

2.00

Practice manager 1 0.00

1.00

Total 8 4.25

12.25

ICDP workforce investment in the AHSRTSHLT: The RTSHLT was comprised of one RTC, two TAWs and two HLWs as at early 2013. The RTC reported that some difficulties in recruiting team members were experienced, but that there has been little turnover since. The team members had been in place for between one month and 18 months at the final stage consultations. The focus of the RTSHLT was on smoking and healthy lifestyles, although the majority of their community level activities related to the latter at final consultations, and included social marketing, sporting events and exercise classes. The two TAWs were trained in brief interventions and were providing this service to community. No formal needs assessment was undertaken to design the RTSHLT’s activities outside of considering practice-level data. The RTSHLT members had recently been integrated into a broader public health team that included AHPs and public health workers, at final stage consultations.

33 Workforce data provided by the former Department of Health and Ageing. Note there are different datasets for each worker type, and each provide point in time snapshots at dates within 2012-13.


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The AHS had an existing drug and alcohol program when the team and public health staff came on board, which included an anti-tobacco program. The AHS also had GPs and AHWs who could provide support for quitting smoking. Thus, the workers were not operating in isolation and had easy opportunities to refer patients seamlessly to services internally. This was working well. The team was also partnering with local, broader social support and recreation services at final stage, such as the local council. Conversely, the team had had limited interaction with health workers outside of the AHS. Practice manager: The ICDP practice manager started his role in early 2013 and had spent his first months determining what his focus should be in conjunction with management staff. By the final stage consultations, he had identified a need for improved patient and clinical information systems within the AHS, better ways to manage and prioritise walk-in patients, and the need to generate income through better utilisation of Medicare items. The AHS was planning for the implementation these activities in early 2012-13.

ICDP workforce investment in the Medicare LocalCtG team (IHPO, ATSIOWs and Care Coordinator): The ATSIOWs, Care Coordinator and IHPO in the Medicare Local worked closely together as part of a CtG team. Patients were referred into the team through 24 different referral pathways. The role of the team was being promoted to the community and health providers through print materials and information sessions as at final stage consultations. The IHPO manages the team, and has worked closely with local practices and the community to promote ICDP programs and increase cultural awareness through providing information and training. The focus of the ATSIOWs in this team structure is to facilitate access to health care for clients. At final stage, they were doing this by providing transport, making appointments, and providing other supports to address client needs. The Care Coordinator was dividing her time between CCSS and a state based care coordination program at final stage. She was on a secondment from another mainstream organisation at the time of final stage consultations, and there were plans for one of the ATSIOWs to take over her role when she leaves. The Care Coordinator often works with clients who have multiple complex needs until their chronic disease is under control, and then hands them over to the ATSIOWs. Because the ATSIOWs can provide transport and liaise with clients around access, the Care Coordinator can work with a larger number of patients, and really focus on chronic disease care coordination. The CCSS Program was implemented at a similar time to the state-based care coordination program at this site, although these programs differ in a number of areas including: target group, as the CCSS program targets Aboriginal and Torres Strait

Islander people whereas the state-based program targets all people with chronic disease;


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setting, as CCSS is based in the community while the state-based program targets hospitals and care post-discharge;

focus, as the state-based program focuses on patients post-discharge, and aims to provide shorter term support, while the CCSS aims to coordinate care over a longer period; and

availability of funds, as the CCSS incorporates SS funds, but there is no such equivalent with the state-based program.

The team structure ensures the ‘clients’ are seen by the most appropriate worker and thus receive the correct level of care, e.g., if a patient requires transport assistance they will only work with the ATSIOW regardless of whether they are a CCSS patient. Having multiple staff within one team was seen to support responsiveness because if one worker is not available, another may be. At final stage consultations the team members had been employed for between six months and two years and there had been very little staff turnover.

Impact of the ICDP Each of the changes expected to occur as result of ICDP investment were found to have occurred at the final stage. These expected changes were: additional healthy lifestyle programs; improved access to pharmaceuticals; reduced financial barriers to accessing health care; increased cultural competency of practices; increase in PIP Indigenous Health Incentive practice participation; improved access to primary health care; improved access to specialist and allied health services; and transport difficulties addressed.In addition to these expected changes identified at baseline, several other impacts were also observed. Overall, the key changes as a result of ICDP investment at this site, with reference to the conceptual framework, were: system capacity: an expanded health workforce, availability of new and

additional programs that were not previously available, leading to increased choice for Aboriginal and Torres Strait Islander people about where they can access services;

access: improved geographical accessibility and cultural accessibility for patients, leading to increased access to services; and

service coordination: improved information and sharing within the region between the mainstream and AHS sectors.

The changes observed relating to each of these conceptual framework domains are explored in detail below.


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Changes to system capacityA number of the ICDP investments in site one represent new or additional Aboriginal and Torres Strait Islander specific programs that align with community demands: The health promotion activities provided by the RTSHLT are a new service in

the AHS, and the staff reported during final stage consultations that that their program goes some way to meeting this previously unmet demand.

The transport and assistance offered through the Medicare Local CtG program is an additional service to the transport provided by the AHS, which cannot meet demand on its own.

The ICDP has also led to general practices offering Aboriginal and Torres Strait Islander health programs, which were not provided in the past, for example: the ICDP measures represent the first Aboriginal and Torres Strait Islander

health program in the Medicare Local (or the DoGP prior to the transition); the IHPO and ATSIOWs are the first Aboriginal and Torres Strait Islander staff

to work in the Medicare Local (or the DoGP prior to the transition); these staff are local which has facilitated good engagement between people

in the community and the Medicare Local; and based on reports from the IHPO, approximately 99 of the 330 GP practices in

the region were registered for the PIP Indigenous Health Incentive as at early 2013.

Through an increased number of mainstream and Aboriginal and Torres Strait Islander specific services offering programs and services to Aboriginal and Torres Strait Islander people, the ICDP has facilitated greater patient choice. Between 2009-10 and 2011-12, the range of services provided through the AHS remained the same but the number of staff increased as demonstrated by growth in the total FTE. See Table 9 and Table 10 below.

Table 9: Summary of chronic disease related services provided by the Indigenous organisation in site one for 2009-10 and 2011-12.34

Service provided by the AHS 2009-10 2011-12Management of diabetes Yes YesManagement of cardiovascular disease Yes YesManagement of other chronic illness Yes YesService maintains health registers Yes YesShared care arrangements for management of chronic disease

Yes Yes

Chronic disease management groups Yes YesTobacco use treatment and/or prevention groups Yes Yes

34 Based on OSR data, provided by the former Department of Health and Ageing. Note – there are a number of limitations with this data which are explored in Appendix A.


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Table10: Summary of Indigenous health organisation service provision in site one for 2009-10 and 2011-12.35

Indicator 2009-10

2011-12

% Change

Number of FTE positions on staff 66.00 70.22 6.39%Number of FTE Doctors providing services 5.00 6.00 20.00%Number of FTE Medical specialists and allied health professionals providing services

3.00 0.16 -94.67%

Total number of episodes of care 18,743

- -

Aboriginal or Torres Strait Islander patient episodes of care as a proportion of total episodes of care

57.47%

- -

Total number of clients 5,266 5,005 -4.96%Aboriginal or Torres Strait Islander clients as a proportion of total clients

62.72%

86.83%

38.44%

Table 10 shows that the total number of clients decreased between baseline and final stages, but this is likely to reflect data limitations, which are detailed in Appendix C. Consultations with the ICDP practice manager at the AHS at final stage suggested that there is an opportunity for the AHS to increase MBS claiming and more systematically provide PIP Indigenous Health Incentive services to patients with chronic disease.

Changes to accessibilityThe ICDP has enhanced accessibility in a number of ways, particularly around access to primary health care services.The work of the ATSIOW has been instrumental in addressing various barriers to accessing health care, such as lack of transport and limited knowledge of the available services within the region.In relation to cultural accessibility, the IHPO worked closely with local practices to increase their cultural appropriateness as described above, with a focus on Aboriginal and Torres Strait Islander identification, building awareness of Aboriginal and Torres Strait Islander specific MBS items and ICDP initiatives such as CtG scripts and the PIP Indigenous Health Incentive. ICDP staff and patients reported that this led to a more culturally appropriate, comprehensive and systematic approach from general practices to providing care to Aboriginal and Torres Strait Islander people. The PIP Indigenous Health Incentive requirement for GPs to undertake cultural awareness training led to approximately 100 practice staff (as reported by the IHPO) engaging in cultural awareness training by 2012-13. While there is the evaluation is not able to assess the impact of this, this is likely to have contributed to improvements in cultural awareness. The number of PIP Indigenous Health Incentive registered patients is illustrated in Table 11. Almost half of the Aboriginal and Torres Strait Islander people in this site were EverIHI as at 2011.35 ibid.


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Table11 Site population PIP Indigenous Health Incentive statistics.

Statistic FigureAboriginal and/or Torres Strait Islander population36 11,503Estimate number of Aboriginal and/or Torres Strait Islander population with a chronic disease37

2987

Patients (EverIHI)38,39 1,484Estimated proportion of Aboriginal and Torres Strait Islander people estimated to have a chronic disease who are PIP Indigenous Health Incentive registered

49.68%

Over time, there was growth in the number of Health Assessments provided to EverIHI patients, assisted by increases in the number of providers providing Health Assessments (Table13). At the baseline period approximately nine per 100 EverIHI patients received a Health Assessment. This had increased substantially by calendar year 2012 with 30 per 100 EverIHI patients having received a Health Assessment (Table 13).The increased in use of Health Assessments was accompanied by an increase in allied health follow-up services after June 2010 (Table 14). The increase in allied health follow up services was not quite as rapid as the increase in Health Assessments. While the number of allied health follow up services per 100 EverIHI patients increased between the baseline period and 2012 (Table 15) the number of allied health services per 100 Health Assessments had decreased slightly.There was no evidence of increased attendances at specialists or of increased numbers of specialists after the baseline period (Table 16). The number of specialist attendances per 100 EverIHI patients increased slightly between the baseline period and 2012 (Table 17), although this was in line with the existing trend. As shown in Table 18, there was no notable change in the trends in GP attendances, numbers of GPs serving the Aboriginal and Torres Strait Islander community and the average attendances per GP at site one. Importantly though the number of GP attendances per 100 EverIHI patients had increased between baseline period and 2012 (Table 19).There was also no noticeable change in trends for pathology tests after the baseline year (Table 20). Similar to GP attendances the number of pathology services per 100 EverIHI patients had increased between the baseline period and 2012 (Table 21).These findings suggest some changes in patient journey for a subset of EverIHI patients at site one. The changes appear as more widespread use of Health Assessments by providers leading to increased numbers of EverIHI patients 36 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra.37 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.38 MBS data supplied by the former Department of Health and Ageing, 2013.39 This is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period. As such the Patients (EverIHI) values may not always match the numbers in the proceeding tables.


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June 2014

undergoing a Health Assessment. This appears to be leading to increased use of follow-up allied health services for these patients. There is no evidence of increased referral to specialists, GP attendances or pathology services but the trend of more of these services being provided to EverIHI patients has continued.

Table 12 Number of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments and average health assessments per provider40, site one, by six month period, 2007 to 2012.41

Six months ending Aboriginal and Torres Strait Islander Health Assessments

Providers of Health Assessments

Health assessments per provider

June 2007 25 11 2.3December 2007 24 15 1.6June 2008 17 6 2.8December 2008 28 14 2.0June 2009 55 24 2.3December 2009 52 22 2.4June 2010 57 19 3.0December 2010 148 55 2.7June 2011 134 72 1.9December 2011 165 66 2.5June 2012 218 93 2.3December 2012 213 91 2.3

Table 13. Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.42

Statistic 2009-10

2012

EverIHI patients 1,452 1,449

Health assessments 109 431Health assessments per 100 EverIHI 8 30

40 Up to June 2010, this is the minimum number of individual providers of Aboriginal and Torres Strait Islander Health Assessments. The actual number may be higher as multiple MBS items were used for these assessments. After June 2010, this is the actual number of providers of MBS item 715.41 MBS data supplied by the former Department of Health and Ageing, 2013.42 ibid.


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Table 14: Number of allied health follow up services43 for EverIHI patients at site one, by six month period, 2007 to 2012.44

Six months ending

Allied health follow-up services

June 2007 44December 2007 49June 2008 53December 2008 87June 2009 118December 2009 101June 2010 112December 2010 225June 2011 225December 2011 261June 2012 293December 2012 249

Table 15. Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site one in 2009-10 (baseline period) and calendar year 2012.45

Statistic 2009-10

2012


Allied health follow-up items 213 542Follow-ups per 100 EverIHI 15 37Follow-ups per 100 Health assessments

13 9

43 MBS subgroup M03—Allied Health Services plus MBS subgroup M11--Allied Health Services For Indigenous Australians Who Have Had A Health Check.44 MBS data supplied by the former Department of Health and Ageing2013.45 ibid.


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Table 16: Number of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site one, by six month period, 2007 to 2012.46

Six months ending Attendances Providers Attendances per providerJune 2007 211 107 2.0December 2007 267 119 2.2June 2008 267 118 2.3December 2008 277 133 2.1June 2009 298 127 2.3December 2009 308 125 2.5June 2010 263 120 2.2December 2010 285 129 2.2June 2011 281 125 2.2December 2011 313 134 2.3June 2012 331 142 2.3December 2012 325 128 2.5

Table 17. Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site one in 2009-10 (baseline period) and calendar year 2012.47

Statistic 2009-10

2012


Specialist attendances 571 656Specialist attendances per 100 EverIHI

39 45

46 ibid.47 ibid.


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Table 18: Number of GP attendances, GP providers and attendances per provider, for EverIHI patients at site one, by six month period, 2007 to 2012.48

Six months ending

Attendances GPs Attendances per GP

June 2007 6,803 689 9.9December 2007 6,971 704 9.9June 2008 7,036 729 9.7December 2008 6,989 724 9.7June 2009 7,134 709 10.1December 2009 7,105 717 9.9June 2010 7,529 741 10.2December 2010 7,803 733 10.6June 2011 8,131 774 10.5December 2011 8,211 745 11.0June 2012 8,125 786 10.3December 2012 8,111 839 9.7

Table 19. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site one in 2009-10 (baseline period) and calendar year 2012.49

Statistic 2009-10

2012

EverIHI patients 1,452 1,449GP attendances 14,634 16,23

6GP attendances per 100 EverIHI

1,008 1,120

Table 20. Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI at site one in 2009-10 (baseline period) and calendar year 2012.50

Statistic 2009-10

2012

EverIHI patients 1,452 1,449Pathology services 9,784 11,22

2Pathology services per 100 EverIHI

674 774



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Table 21: Number of pathology services for EverIHI patients at site one, by six month period, 2007 to 2012.Six months ending

Pathology services

June 2007 4,043December 2007 4,172June 2008 4,400December 2008 4,408June 2009 4,913December 2009 4,777June 2010 5,007December 2010 5,287June 2011 5,669December 2011 5,741June 2012 5,679December 2012 5,543


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Table 22: Number of PBS scripts dispensed to EverCtG patients by six month period, site one, 2007 to 2012.51

Six months ending

Scripts

June 07 18,690

December 07 22,595

June 08 21,490

December 08 25,912

June 09 23,980

December 09 27,708

June 10 25,682

December 10 32,276

June 11 32,036

December 11 38,545

June 12 39,007

December 12 41,092

There was consistent growth in PBS scripts dispensed to EverCtG patients leading up to June 2010 for all sites. At site one, the growth in the number of PBS scripts dispensed to EverCtG patients accelerated further after June 2010, most likely related to the start of the PBS Co-payment. The number of scripts dispensed to EverCtG patients in 2012 was 50 per cent higher than the number in the baseline year of 2009-10 (Table 22).Together the MBS and PBS data provides evidence of increased service delivery to Aboriginal and Torres Strait Islander people by GPs (and pharmacists) at site one. The results for EverIHI patients suggest there was increased monitoring (through health assessments) for Aboriginal and Torres Strait Islander patients with or at risk of a chronic disease. This appeared to have led to increased pathology testing and also increased use of allied health follow up services. This last increase appears to have been appropriately targeted, as the increase in use of follow up services was substantially lower than that for health assessments.

51 Pharmaceutical Benefits Scheme data. Provided to KPMG by the Department of Health, 2013.


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This is consistent with follow up services being targeted to the subgroup of assessed patients with an identified need.CCSS represents a new source of funding for access to specialist and allied health services, and medical aids. This has relieved some of the financial barriers to these services for patients in this site were significant, while: there were some specialist and allied health services available for free

through the AHS at baseline, these were in high demand; and some specialists provided bulk billing services through the region’s hospitals,

these had long waiting lists and people had to travel to appointments, and many do not have transport to do so.

Changes to service coordinationSince the transition, the Medicare Local commented that it has an increased emphasis on local networking and collaboration around Aboriginal and Torres Strait Islander health. The IHPO helped to establish three local inter-agency meetings, which bring together the AHS, the Local Health District (LHD) and the Medicare Local staff at different levels to discuss Aboriginal and Torres Strait Islander health. Topics for discussion include: current initiatives in Aboriginal and Torres Strait Islander health, new

programs and new services; issues identified for patients, such as transport problems or a gap in available

services; and where services have patients in common, how best to provide for the

patient’s needs.According to the IHPO, this has led to a more collaborative approach to addressing patient needs.The work of the RTSHLT, according to team members, has led to stronger linkages between the AHS and other organisations in the community such as the local council. AHS staff reported at final stage, however, that the organisation still does not have good working relationships with some other local Aboriginal and Torres Strait Islander services, and this is a potential area for improvement. Finally, ICDP staff at the Medicare Local and the AHS both reported that they make an effort to link patients in with relevant internal services as well as external services, for example, the mental health and drug and alcohol programs within each of these organisations. Some service system enhancements observed at this site stemmed from broader health reform and other sources of investment into health and Aboriginal and Torres Strait Islander health: Through the transition to Medicare Locals, structures were established to

support better service coordination, such as additional inter-agency meetings. The commencement of the personally controlled electronic health records (PCEHR) rollout led to an increased focus on collecting and maintaining good client and practice data.

Other sources of funding, such as through the Access to Allied Psychological Services (ATAPS) program and the Healthy for Life program, have supported


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complementary service provision for people with mental health problems and young people.

Impact of the ICDP on the patient experienceFigure 3 below reflects the final patient journey at site one. The yellow boxes reflect ICDP investment and facilitators observed as a result of the ICDP. Important changes to the patient journey were noted: Enhanced capacity in preventive health through implementation of the

RTSHLT. This provides community members with services and supports to reduce the likelihood that they will progress to being diagnosed with a chronic disease and supporting increased and timelier engagement with primary health care services. At the final stage consultations, the RTSHLT and community members participating in RTSHLT activities reported a number of patient impacts relating to knowledge and attitude change. They were increased and sustained participation in healthy lifestyle activities such as exercise groups, better understanding amongst community members of health risk factors and the services available in the region to address these, and changes to peoples’ attitudes around living a healthy lifestyle.

Improved accessibility to the mainstream primary health care system associated with the investment through the Medicare Local and the PIP Indigenous Health Incentive, PBS Co-payment. This provides patients with choice about how they access services.

An important component of this has been improving the cultural competency of general practices. Through the work undertaken by the IHPO and the impetus for change provided by the PIP Indigenous Health Incentive, patients now have access to general practices that are culturally relevant. The presence of ICDP initiatives such as the PBS Co-payment has raised the profile of Aboriginal and Torres Strait Islander health, and has been further supported by advocacy and promotion work undertaken by ICDP workers such as the IHPO and ATSIOWs. The result has been increased cultural appropriateness of services from pharmacies and GPs.

‘The chemists are really good. I get CtG but I also need Webster packs. They give them to me for free because they realise it helps me. Nothing is too much trouble for them. They understand what we need.’52

The CtG team in the Medicare Local reported at final stage consultations that as a result of their programs, there is increased access to health care by Aboriginal and Torres Strait Islander people, particularly pharmaceuticals, GP services and specialist services. Addressing the costs of health care is also an important component of

improving access. The SS funds and CtG scripts initiatives have reduced this significant barrier to services for Aboriginal and Torres Strait Islander people and the CtG team commented that this has led to increased access to specialist services and medicines.

Improved awareness of health services and confidence to navigate the health system. This is associated with the appointment of dedicated workers

52 Community member, site one.57

KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards

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(ATSIOWs and a Care Coordinator) to work with patients to address this barrier. This has resulted in improved patient understanding of the services available in the health care system and how to access these.

‘In the past I didn’t go to my appointments. I didn’t want to wait for the train, and then travel for 40 minutes when I was feeling sick. I also didn’t really see the point in my appointments – why should I go to the hospital when I’m not sick? I was thinking. When [the ATSIOW] started, she said she could drive me to the hospital. This was really helpful. Then I found out about [the Care Coordinator], she organised my appointments for me, and came into the appointments to help me understand the doctor. She also explained that I need to go to the appointments. I realised that I needed to go there to prevent [my condition] getting worse.’53

It has also resulted in increasing the number of patients who are more engaged with health care than in the past.

‘Early on, a lot of doctors didn’t know about CtG scripts. Some of them weren’t interested in providing them ether. One of my friends told me about them and I thought, that sounds pretty good. My doctor wasn’t part of the program [PIP Indigenous Health Incentive] but I asked them to sign up, and they did. Now I can afford my medication.’54

Improved access to transport. This was identified as a significant barrier at baseline and is likely to continue to be a barrier into the future. However, the work of the ATSIOWs, who have provided transport to patients to access a range of programs and services, has gone some way towards addressing this.

Consultations did not reveal that the ICDP had impacted on data collection and clinical information systems within the AHS sector yet, but the ICDP Practice manager is likely to support this in the future.

Ongoing challenges related to ICDPA number of ongoing challenges were identified at site one at the final stage, which may be factors limiting the impact of the ICDP: PIP Indigenous Health Incentive registration rate. Ninety-nine of the 330 GP

practices in the region are PIP Indigenous Health Incentive registered by early 2013, which leaves over two thirds of practices un-registered.

Lack of services for under 15 year olds with chronic disease. ICDP staff reported that there are many patients under 15 with chronic conditions such as asthma that would benefit from the support of the CCSS Program and PIP Indigenous Health Incentive.

The size of the population. The area is densely populated and he Aboriginal and Torres Strait Islander population is large and relatively mobile. ICDP workers reported that this makes it impossible to meet demand.

Difficulty of the task at hand. The RTSHLT reported that getting people to change their lifestyle behaviours is challenging and can make engagement of the target population difficult.

53 ibid.54 ibid.


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3.1.3 Final assessment, Table 24, Table 25 and Table 25 below draw together the information presented above about site one at the final stage. Against the conceptual framework domains characteristic, this table provides: the rating the evaluators gave the site at baseline55; the rating the evaluators gave the site at final stage56; the key changes observed; and what these changes appear to be attributable to.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.Figure 1 and Figure 2 provide a visual representation of the findings within this chapter as at baseline and as at the time of the final evaluation. Each figure is presented as a systems map which details, on a single page, the health services provided within the community, primary, secondary and tertiary sectors within the site. Each patient services map includes the: AHS and mainstream services/supports located within the site; ICDP staff and programs (post-ICDP map only); linkages between services, where these are in place; and identified facilitators and barriers to patient accessibility to these services.

55 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory. 56 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory/moderate change from a low base. 3= notable change from baseline.


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Table 23: Assessment of change against the conceptual framework – domain 1: system capacity.Characteristics

Base

line

rati

ng

Fina

lra

ting

Key changes Attribution


2 3 Although there were no gaps specifically identified in the physical infrastructure at baseline, ICDP staff working in the Medicare Local now have access to larger office space. The AHS also has built new facilities and staff have access to laptops. Partnerships between the AHS and other organisations have been leveraged to access other facilities, such as gyms. There is still no access to cars for ICDP workers.

The transition to Medicare Local led to new offices for the ICDP staff.Some of the ICDP funding supported the Aboriginal Medical Service (AMS) to expand. Other funding used for the expansion was provided through other sources.


2 3 There are many more Aboriginal and Torres Strait Islander health staff in the region. The Medicare Local has Aboriginal and Torres Strait Islander staff for the first time.At the AHS, while the ICDP staff represents additional workers, the AHS is constantly funded for different programs that have staff attached; thus, new staff are not uncommon.

ICDP has created an additional 12.25 FTE positions in the region including 4.25 FTE in the mainstream sector.


1 2 Transport was a significant gap in meeting patient needs at baseline, which is being addressed through the ICDP.The increasing number of Aboriginal and Torres Strait Islander specific services has helped to meet high demand from the region’s large Aboriginal and Torres Strait Islander population. For example, there are new workers whose roles meet the community needs such as smoking program, access to the gym. From the AHS’s perspective, programs operating only in general practices are not meeting the demands of clients who solely use the AHS.

The ICDP has funded any new programs which meet needs: CtG scripts, CCSS, ATSIOWs, the PIP Indigenous Health Incentive and RTSHLTs.

60

KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards Legislation.


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Characteristics

Base

line

rati

ng

Fina

lra

ting


Overall, because the population is so large it is not possible to meet all peoples’ needs.


1 1 There have been some improvements in practice and clinical information systems; the Medicare Local and some GP practices are moving to, or planning to move to, systems that support information sharing and improved data collection.Management and clinical information systems are still poor within the AHS practices, despite good intentions at baseline.

The shift within the mainstream sector has been driven through transition to Medicare Local and the PCEHR. The CtG scripts and PIP Indigenous Health Incentive measures present impetus for change in the mainstream sector, but this has not yet translated to region-wide improvements.The ICDP practice manager is planning to improve the AHS’s systems in the future.


2 2 Both the AHS and Medicare Local (DoGP at baseline) appeared committed to Aboriginal and Torres Strait Islander health at baseline.The Medicare Local perceives that an increased focus on Aboriginal and Torres Strait Islander service provision has occurred, both within the mainstream health sector and more broadly (i.e., from housing non-government organisations (NGOs)). The AHS disagrees, stating that some of this focus would not continue without the ICDP funding and incentives.The AHS reports that it has always had a commitment to Aboriginal and Torres Strait Islander health and will continue to do so in the future.

ICDP funding facilitated an initial, greater focus on Aboriginal and Torres Strait Islander health. The funding available to organisations such as Medicare Locals and the incentives available to GP practices may contribute to this focus being maintained.ICDP staff have promoted ICDP initiatives within the mainstream sector, which may have raised the profile of Aboriginal and Torres Strait Islander health.

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Table 24: Assessment of change against the conceptual framework – domain 2: access. Characteristics

Base

line ra

ting

Fina

lra

ting


Services are geographically accessible to patients, or support physical access e.g., through provision of transport or outreach.

1 3 The area is large but there is a lot of public transport around the area and to and from the city. However, many patients do not have access to private transport and the AHS transport service cannot meet demand. Since the ICDP started, there are additional supports to assist patients to get to service locations, such as transport.New programs providing increased access to medicines, preventive health workers, specialist, allied health services, and primary health care, have also been put in place within the Medicare Local, general practices, AHSs and community pharmacies.Further, there has been a focus on promotion of available health services and programs to Aboriginal and Torres Strait Islander community members.

Enhanced transport services (ATSIOWs).Information about available health services(ATSIOWs, CCs, and IHPOs)New and additional services (various).Some of additional allied health and specialist services within the AHS have been funded through sources other than the ICDP.


1 2 Financial barriers to access have been addressed through the SS funds, which represents a new source of funding for access to specialist and allied health services, and medical aids, and CtG scripts which have reduced the financial barrier to accessing medicines. Enhanced transport services may also have assisted patients for whom transport to health services represented a financial burden.

ICDP programs have reduced financial barriers (CtG scripts, CCSS).


1 2 At baseline, both the Medicare Local (then DoGP) and AHS targeted broad target groups including special needs groups such as people with chronic disease. The identified need for more Aboriginal and Torres Strait Islander specific programs is being met through the ICDP but workers report that they can never meet the significant demand resulting from the size of the community.

As above, ICDP workers have provided programs not available previously in health promotion (RTSHLT), as well as the services provided through CCSS and by ATSIOWs.

There are protocols or mechanisms in place to support

2 3 At baseline, the majority of general practices were reported to be culturally competent, and the AHS provided care

The PIP Indigenous Health Incentive has provided impetus for change. The

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Characteristics

Base

line ra

ting

Fina

lra

ting


culturally appropriate care such as inclusion of family members in appointments and decision making.

coordination and AHLO services. Further to this, the IHPO reported changes within practices around cultural competency, such as better Aboriginal and Torres Strait Islander identification. Some GPs are still not considered culturally competent by community members.

IHPO has worked with GP practices to support practice change.


2 3 Since baseline, there were examples of this provided by patients such as posters, signs and Aboriginal and Torres Strait Islander artwork within services. 99 general practices (of 330 in the region) were registered for the PIP Indigenous Health Incentive at early 2013. Through this, changes such as Aboriginal and Torres Strait Islander identification practices were facilitated.

As above, the PIP Indigenous Health Incentive has provided impetus for change. The IHPO has worked with GP practices to support practice change.


2 3 While many general practices were considered receptive at baseline, with increased understanding of the importance of Aboriginal and Torres Strait Islander health initiatives, receptivity has increased. The incentives available to GPs have supported this.

The IHPO has worked with GP practices to build their understanding through providing information and training.


2 3 Many of the ICDP staff are local Aboriginal and Torres Strait Islander people. Other staff have built good relationships with the community, such as the Care Coordinator.

The ICDP has created positions in this region that are most appropriately filled by local Aboriginal and Torres Strait Islander people, such as ATSIOW and RTSHLT positions.

Cultural awareness training and immersion is available to the health workforce.

1 2 There has been an increased uptake of cultural awareness training. As at early 2013, 100 general practice staff in the region had done cultural awareness training (this reflects around one person per PIP Indigenous Health Incentive registered practice, which is lower than the required number of two). There is a perception from the AHS that some GPs see the cultural awareness training as a ‘tick box’ exercise.

Cultural awareness training is required through the PIP Indigenous Health Incentive.

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Table 25: Assessment of change against the conceptual framework – domain 3: service coordination.Characteristics

Base

line

rati

ng

Fina

lra

ting



1 3 Three additional inter-agency meetings have been created. These bring together staff at different levels: staff ‘on the ground’, management staff and executives. From the AHS’s perspective, there are better partnerships between the mainstream and AHS sectors, which have led to better networking and information sharing.

These have been driven by the establishment of the Medicare Local in the region; although the IHPO has been a big part of this, thus the ICDP has had a role in this change.

There is a focus on patient centred planning and care delivery involving multiple providers.

1 2 The inter-agency meetings have brought together the Medicare Local, AHS, LHD and other parties involved with Aboriginal and Torres Strait Islander people. This supports better communication about patients and avoids duplication. There is room for improvement in some parts of the system in terms of the ‘patient focus’. Similarly to at baseline, patient reported mixed views about continuity of care and coordination.

As above.

Informal mechanisms or practices that support service coordination and patient centres planning and care delivery (e.g., referral protocols, service directories. cross-agency awareness training) are in place.

1 2 There are some cross referrals between the Medicare Local and the AHS. These are relationship-based, and rely on individuals to keep them going. The AHS does not have good relationships with other Aboriginal and Torres Strait Islander services in the region.

As above.

Formal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, and shared information systems and joint planning) are in place.

0 3 No formal mechanisms were reported at baseline. Now, the Medicare Local and AHS share some of the CCSS funding and joint planning is undertaken between the AHS, Medicare Local and local health district (LHD) through the inter-agency meetings.The CtG team in the Medicare Local receives referrals from 24 formal referral pathways that have been developed by the IHPO.

As above.

Services within the system are 2 2 There are different perceptions on this issue; the As above.

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Characteristics

Base

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ng

Fina

lra

ting


complementary and there is no duplication. Medicare Local indicates that things are working well, and services are not duplicative, but the AHS states service delivery is ‘fractured’.

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Site one (SSE) pre-ICDP – patient journey mapCo

mm

unity

Prim

ary

Seco

ndar

yTe

rtier

y

Scripts

Ongoing treatment and support Diagnosis and treatment

Ongoing access to services

ICDP linkage

Non-ICDP linkage

ATSI service/support

Mainstream service/support

Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

Ongoing access

Ongoing access

Referral

Ongoing access

Referral

Referral

Ongoing access

Ongoing access

Ongoing access

Ongoing access *Barrier expected to be reduced by

ICDP fundingIHS AHPs

IHS

IHS visiting specialists

Lack of transport*

State based community

health centre

Visiting/local specialists

Waiting times

Welfare

GP Practices

Cost of services

IHS H4L program


Location - in IHS

Local Pharmacies Local Pharmacies

Cost of follow up

Support Services

Hospital based services – dialysis,

specialists

IHS transport

Costs associated with behaviour

change

Cost of services

Waiting times

IHS

GP Practices


specialists

Housing

Healthy lifestyle programs (DoGP)

Limited readiness to

change* Community based health promotion

programs (state funded)

Waiting times

IHS AHPs

Lack of transport*

Lack of confidentiality


Hard to get appointment

Lack of cultural awareness

Prevention

Transport part of some programs

Program promotion&

awareness raising

Programs not aligned to community

needsLack of private

transport

Referral

Location of program in IHS

Program promotion

Services/approaches not personalised

Costs of programs*

Cost of transport*

Bulk billing

Referral

Cost of follow

up

Cost of medicines*

Trusted relationship with GPs

Lack of cultural appropriateness*Medicines

subsidised through QUMAX

Employment

Education

Referral

Figure 1: Patient service map site one: Baseline. Source: KPMG.

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Site one (SSE) with-ICDP – patient journey mapCo

mm

unity

Prim

ary

Seco

ndar

yTe

rtier

y

Scripts

Ongoing treatment and support Diagnosis and treatment


ICDP linkage

Non-ICDP linkage



ICDP staff/program

Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

*ICDP facilitator

Ongoing access

Ongoing access

Referral

Ongoing access

Referral

Referral

Ongoing access

Ongoing access

Ongoing access

Access andcare

coordination

Ongoing access Barrier reduced by ICDP funding

IHS AHPs

IHS


Care Coordinator

Lack of transport

State based community

health centre


Waiting times

Welfare

GP Practices

Cost of services

IHS H4L program


Location - in IHS

Local Pharmacies Local Pharmacies

Cost of follow up

Community knowledge of ICDP and benefits*

Support Services


specialists Improved access*

CtG scripts not available on discharge

IHS transport

ATSIOW

Costs associated with behaviour

change

Cost of services

Waiting times

Linkage with IHS secondary service

through ICDP workers, including

transport*

IHS

GP Practices


specialists

Housing

Healthy lifestyle programs (DoGP)

IHPO

Limited readiness to

change Community based health promotion

programs (state funded)

Transport*

Waiting times

ATSIOW

IHS AHPs

Lack of transport

Lack of confidentiality

RTSHLTprograms


Hard to get appointment

Lack of cultural awarenessPromotion of ICDP

services and benefits*Linkage to key

events*

Prevention

Team not aligned with

organisational strategy

Programs not aligned to individual needs


Community awareness of team*

Transport part of some programs

Program promotion&

awareness raising

Programs not aligned to community

needsLack of private

transport

Referral

Location of program in IHS

Program promotion


Costs of programs

Cost of transport

Bulk billing

Referral

Cost of follow

upAccess and

care coordination

Reduced cost medication*Some

pharmacists not engaged with ICDP

Trusted relationship with GPs

Lack of cultural appropriateness

Transport* Not PIP IHI registeredMedicines subsidised through QUMAX

Increased awareness

of CtG scripts*

Transport*

Employment

Education

New types of AHP*

Referral

Figure 2: Patient service map site one: Final. Source: KPMG.

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3.2 Site two (Major City)3.2.1 Site two at baseline This site covers four Local Government Areas (LGAs) in a capital city. Although the Aboriginal and Torres Strait Islander population is a small proportion of the overall population in this area, it is a community and cultural centre and many people travel in from surrounding areas to access services here.This site is home to many people who are identified as vulnerable or disadvantaged, including those living in high-density public housing and recent migrant populations. At baseline, this area was not considered a district of workforce shortage for general practice. As an urban centre, the availability of health and social services in the area is relatively high and at baseline, community members generally reported that the service system was large, comprehensive and culturally appropriate. The barriers to accessing services in this site reflected issues like the cost of accessing specialist and allied health services, difficulties for elders and people with young children to use the public transport available to access services and limited access to private transport.Table 2626 provides summary statistics for site two, covering the local population profile, participation in the PIP Indigenous Health Incentive and conduct of Health Assessments.

Table 26: Summary of population, engagement in PIP Indigenous Health Incentive and Health Assessments in 2009-10.57

Indicator StatisticEstimated Resident Population (2011 Census) 512,685Aboriginal/Torres Strait Islander population (2011 Census) 3,302Proportion of Population identifying as Aboriginal and Torres Strait Islander

0.60%


544


16.50%


59

Site two includes one hub, two major hospitals and six minor hospitals, many GPs and pharmacies, an AHS, three after-hours GPs services and 10 community health centres. Prior to the implementation of ICDP no DoGP had an Aboriginal and Torres Strait Islander health program and no general practices were found to have Aboriginal and Torres Strait Islander staff.

57 Based on ABS population estimates and Medicare data provided by the former Department of Health and Ageing.


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System capacity

General practice systemThere were many private, general practices within the site. The DoGP responsible for most of this area received ICDP funding in 2009-10, and employed an IHPO and ATSIOW at the end of that financial year. The DoGP was collating data about PIP Indigenous Health Incentive practice and patient registration, identification of Aboriginal and Torres Strait Islander patients in general practices and the roll out of Health Assessments.Many specialist services were accessible in both secondary and tertiary settings in the region at baseline, for example, through a myriad of private providers and hospital clinics. Two major public hospitals and several smaller public and private hospitals were found to be located within the site. Additional tertiary and specialist hospitals were identified in close proximity. Other services available in the area included numerous specialists, social and community support services, and numerous community pharmacies.At baseline, a broad range of chronic disease related services were available through the hospitals within the area. The major public health service was providing a range of chronic disease related services including speciality services for cardiology, pain management, cancer screening, endocrinology and diabetes, nephrology and dialysis, oncology and respiratory medicine and a broad range of allied health services including diabetes educators and social workers. Around 10 state funded community health centres were operating across the site offering relevant services such as low cost allied health (for example podiatry, dietetics, preventive health), diabetes self management and early intervention in chronic disease services.In the area, many community-based programs were being provided including diabetes support and education, healthy living and nutrition groups, and group exercise programs. Other than those provided by the AHS (including a diabetes education group, community kitchens and exercise for elders group), these community based services were primarily targeted at the general population and not designed to specifically target Aboriginal and Torres Strait Islander people. None of the community members consulted during baseline reported accessing mainstream community health and support services.

Aboriginal and Torres Strait Islander service system The AHS was found to be large and well established. Aboriginal and Torres Strait Islander people from across the site, and indeed beyond the local area, travel to the AHS for primary health care. The AHS is large and includes a broad range of clinical and non-clinical services including but not limited to primary health care, dental health, diabetes care, exercise programs and counselling. The AHS become a Healthy for Life site in 2009, and the Healthy for Life program includes a focus on chronic disease prevention and management. The AHS was using a standard electronic Patient Information Recall system to manage patient information. In 2009-10, the AHS had a total of 104 staff – eight of which were doctors, five were specialists or AHPs and 22 AHWs. In addition, the AHS was hosting 1.2 visiting specialists.


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A total of 38,420 episodes of care were provided in 2009-10 (34,488 to Aboriginal and Torres Strait Islander patients). The majority of client contacts (total 47,026) were by doctors (19,358), followed by AHWs (8,938), nurses (5,421) and specialists/AHPs (4,539).Table 136 below provides a summary of chronic disease related services provided by the AHS in site two AHS in 2009-10.

Table 27: Summary of chronic disease related services provided by the AHS in site two in 2009-10.58

Chronic disease related services provided by the AHS in site two

Yes/No


Yes

Chronic disease management groups YesTobacco use treatment/prevention groups No

AccessBaseline consultations indicted that many Aboriginal and Torres Strait Islander people were accessing both AHS and general practices. People reported that it is often more convenient to go to a GP located closer (than the AHS) to their home, and find that many general practices in the area provide culturally appropriate care. Other reasons for attending general practices included a perception that their privacy is better protected and there are shorter waiting times. Community members reported that word gets around if someone has a bad experience with a particular provider, and others will avoid that provider/service as a result. The AHS is staffed by many Aboriginal and Torres Strait Islander people and non-Aboriginal and Torres Strait Islander people with an understanding of culturally appropriate care. At baseline, AHWs had a prominent role in clinical care, providing the most client contacts behind doctors. AHS staff reported that they were connecting patients to appropriate and accessible specialist services by establishing referral pathways with providers who had demonstrated culturally appropriate care and were more likely to bulk bill where possible. At baseline, the local AHS was open Monday-Friday from 9am-5pm and for limited hours on Saturdays. No afterhours services were reported in 2009-10. The AHS was providing some patient transport and was found to be accessible by various forms of public transport. A limited home visiting program was also available at baseline. Community members reported that cost and transport are the main barriers for many people accessing specialist services.

58 Based on information gathered during site visits and research. 70


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The hospital was found to have a long standing Aboriginal Health Program which included employment of Aboriginal Hospital Liaison Officers (AHLO) at baseline. The role of the AHLO is to ensure culturally appropriate care is provided to Aboriginal and Torres Strait Islander people who require hospital based health care. The hospital was also working with the local AHS through an advisory body to ensure that the hospital is making a positive contribution to the health of local Aboriginal and Torres Strait Islander people. The hospital had implemented a toolkit to improve cultural sensitivity of all staff. The major hospital was in close proximity to various forms of public transport and offered a very limited transport service.

Service coordinationConsultations with local services and ICDP workers as baseline indicated that coordination between mainstream and AHS was occurring, but was largely facilitated by personal relationships and networks rather than formal mechanisms. The clear exceptions to this were the advisory body for the tertiary public hospital, which included AHS representatives, and the employment of the DoGP ATSIOW at the AHS one day a week. This allowed for informal information sharing and collaboration between the Division and the AHS. At baseline, the AHS reported a positive relationship with many general practices in the area, particularly the major hospital as well as some specialists and local pharmacies. Coordination of care at the patient level was likely to be highly variable depending on the approach taken by individual doctors. Similarly, coordination between specialists and primary care providers was also likely to be highly variable in a site with so many different providers. See page 32 for some insights into patient perspectives of coordination. Overall, service providers reported that the service system is effective in key areas of service coordination – with the Division providing 9/10 ratings for the system’s performance across all of these areas, and the AHS providing 7/10 ratings.59

Patient experienceAboriginal and Torres Strait Islander people have access to a wide variety of services at this site. People have many options in terms of the types of services they access and the way they access these services. Barriers exist, however, in terms of transport and the costs of health care.

Prevention The key prevention issues identified by community members were: Even with good access to healthy food and exercise programs, and lots of

support to quit smoking, people still find it difficult to change their lifestyles. People are managing difficult social problems (such as access to housing,

alcohol and drug addiction and family conflict), which mean making changes like quitting smoking are not priorities.

59 Where 10 is very effective service coordination and 0 is ineffective service coordination. Based on information collected during site visits.


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Community members identified smoking, drinking alcohol, eating take away and lack of exercise as significant problems in the community. People expressed strong concerns about the health and wellbeing of the community generally, as well specific concerns about the prevalence of chronic disease and reduced life expectancy.

‘All those [chronic] diseases are here in our community - also cancer and mental illness. Too many people have these 60diseases now.’

Smoking was identified as the most significant issue; however, community members all agreed that people are smoking less (relative to a historically high smoking rate) and people are much more aware of the need to smoke outside, not in cars and not around babies and children.

‘Lots of people still smoke, but not as many as used to. People don’t smoke inside the house or around kids as much now.’61

Community members talked about the difficult and challenging nature of overcoming nicotine addiction. Most people agree that people need to be highly personally motivated to quit, and this decision was often associated with pregnancy or the arrival of a new baby in the family. People also identified mainstream media campaigns and the rising cost of cigarettes as motivators for some people. Community members felt that children and young people are exposed to strong anti-smoking messaging and education through their schools. Some community members reported that for many people in the community, their biggest concerns are around access to housing, interaction with the justice system, family breakdown or dealing with alcohol and drug addiction. In this context, quitting smoking is not seen as a priority, and some people see ‘having a smoke’ as their only real comfort.

‘Some people are looking at their drinking and drugs; smoking is not their biggest problem.’62

People also spoke about the pressure to smoke still being strong because so many community members still do so. There was a general sense that this was changing though.The community members consulted were able to identify many options for support for people who want to quit smoking. People identified their doctor as being able to provide support and discussed various pharmacotherapy options including NRT products and Champix.

‘When people want to quit they will go to the doctor, usually get some patches or something.’63

Access to food is good in the area, however, traditional hunting and gathering is not possible due to the urban environment. Fruit, vegetables and fresh meat can seem expensive, even though people actually recognise that takeaway food is even more expensive.

‘We try to go to the fruit & veg markets because they are fresher and

60 Community member, site two.61 ibid.62 ibid.63 ibid.


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cheaper. Also – sometimes they do home deliveries which is helpful for oldies and mums.’64

Community members consulted demonstrated high awareness of chronic disease risk factors and identified many preventive health programs and activities available within the region. The group agreed, however, that most programs are targeted at specific groups, such as elders and people with diabetes. Options for other groups, like young mums, or men, were seen to be less available.

‘There are lots of sport and exercise groups.’65

‘They have a dietician here [at AHS]; they can tell you how to budget for food and what to buy.’66

‘There are lots of things for diabetes and lots of things for elders but not really for younger people.’67

One of the barriers to exercise for children and young people identified was the costs associated with registration, insurance and equipment to participate in organised sport such as Little Athletics or football teams.

Diagnosis and treatment The key diagnosis and treatment issues identified by community members were: It is common for people to access both the AHS and a mainstream provider to

meet their primary health care needs – this can create service coordination challenges.

Apparently limited access to allied health care, and limited understanding of options for accessing these services.

Challenges for elders and families to access specialist services including service costs and transport.

Aboriginal and Torres Strait Islander people in this site access many different health care services – both local mainstream providers and the AHS. For some community members, travelling to the AHS for all primary health care is not seen as convenient. Visiting local doctors means less travel time and often shorter wait times.

‘People come here [AHS] and they go their local doctor.’68

Most people usually access primary health care to address an acute problem, rather than as part of a treatment plan for any chronic disease. The exception within the group consulted was elders, who reported that they do see the doctor regularly for a general check-up. People had either identified clinics that offer bulk billing or were willing to pay for the convenience of attending a local clinic.Community members reported that there are groups within the community that do not access health care. These groups generally include men, transient people

64 ibid.65 ibid.66 ibid.67 ibid.68 ibid.


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who may move around either within the city or between the city and regional areas, and those people experiencing homelessness.

‘Most people are ok [willing] to go to the doctor, but if they are just passing through or if they are homeless they probably won’t go.’69

Community members also reported that access to specialists is good in this site, with many different ones from which to choose. People tend to go to specialists they have seen before or those who family members or friends have been to – this is seen as a way to make sure they are culturally safe providers. While people reported that there are sometimes waiting lists to see specialists, they were not seen to be unreasonably long.People identified the costs associated with accessing specialist and ongoing chronic disease management as a concern, and challenges around managing transport to appointments as the biggest challenges. Even these challenges, however, were seen to mainly apply to older people, people with disabilities and people with young children. People reported that there is actually really good public transport in the area – it is just not necessarily easy for everyone to use it. The AHS does provide a transport service; however, community members reported that access was not universal or unlimited.

‘Some transport is available to get you to appointments – it’s not for everyone though.’70

The ATSIOW in this site was not providing transport, although this was identified by the ICDP staff as being a need for people accessing general practices who were therefore unable to rely on the AHS transport service. Community members consulted were aware of and had accessed some allied health services, however, it was reported that people are concerned about the costs of these services if accessed from outside the AHS service system. Community members did not seem to be aware of opportunities to access many allied health services through community health centres at significantly reduced costs.Several group members identified the benefits of CtG scripts in supporting the chronic disease management. While previously people had been forced to travel to the AHS to access free or subsided medications, people were now able to get their local doctor to write them a CtG script. The cost of medication was identified as a major concern, again particularly for elders and young families where one or more members suffered with a chronic disease requiring extensive management and treatment. Table 28 shows professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.

69 ibid.70 ibid.


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Table 28: Professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011. Professional Attendances 2009/10





4,748 2,081 544 8.7 3.8

Ongoing treatment and supportKey ongoing treatment and support issues identified by community members are: People experience frustrations caused by an apparent lack of service

coordination within and between health services. People have good access to a range of service but lack access to care

coordination and support services.While community members in this site agree that there are lots of services available, coordination within and between services was seen as poor by some. People expressed frustration with an apparent lack of communication between general practice and specialist services, between hospital and general practice and between different specialists. It should be noted that these frustrations are not necessarily particular to this site or this cohort of patients.

‘I have to tell the same story over and over again, they [doctors] should talk to each other more.’71

Several community members expressed a view that providers are too focused on getting patients in and out that they do not take time to get to know community members or to understand their personal and family situations.

‘They [providers] are just interested in getting their fees; they don’t really talk to you or care about you.’72

Community members know that they can go to the GP (AHS or mainstream) for help and support once they have been diagnosed with a chronic disease. People also expressed a view, however, that there is limited non-clinical support to help people understand and manage their chronic disease, which some people feel is necessary. People talked about wanting access to a support service that would help with things like scheduling appointments, advising on service options, discussing treatment options and assistance with social problems that may impact on chronic disease management.It’s hard to get support, to find someone to talk to who knows how everything works.’

71 ibid.72 ibid.


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Baseline assessment Table 29 below draws together the information presented above about site two at the final stage. Against conceptual framework domain characteristics, this table provides the rating73 the evaluators gave the site at baseline.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.

73 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory.


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Table 29: Assessment against the conceptual framework.Domains Characteristics Ratin

gAssessment

System capacity


2 The site included significant physical infrastructure in both AHS and mainstream sectors, and most services were able to respond to ICDP investment.


2 The site had a large and well-established AHS and many mainstream providers to meet community needs. Some ICDP workers had already been recruited at baseline, and plans were in place to recruit two additional funded positions. Aboriginal and Torres Strait Islander staff were recruited to the mainstream sector.


2 The range of services was sufficient to meet community needs. The ICDP was adding services such as preventive health, which matched identified community needs.


2 This was evident from both AHS and mainstream consultations. This site is in an area of high accreditation for health services.


2 The AHS and DoGP demonstrated strong commitment to Aboriginal and Torres Strait Islander health and there was good engagement with the ICDP from senior leadership.


1 Services were dispersed throughout the site and, despite good public transport, some community members had difficulty accessing services.

Services are financially accessible to patients. 1 Several examples of affordable health care options were identified (e.g. bulkbilling GPs, free specialist and AHP service through the AHS), however the cost of health care was identified as a major barrier by many community members.


2 ICDP activity was in place across multiple organisations, including within both mainstream and AHS sectors in this site,

77KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards Legislation.


June 2014

Domains Characteristics Rating

Assessment

and addressed identified barriers and service gaps.There are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments and decision making.

1 This was particularly good at the AHS, and was likely to be highly variable across general practices. The major hospital was undertaking significant work in improving cultural appropriateness.


1 This was particularly good at the AHS, and was likely to be highly variable across general practices.


1 This was likely to be highly variable across general practices. Practice registrations or PIP Indigenous Health Incentive was 20 per cent at baseline, indicating that additional engagement from the mainstream sector could improve in relation to primary health care.


2 The AHS employed many local Aboriginal and Torres Strait Islander people, and the ICDP staff at the DoGP were local Aboriginal and Torres Strait Islander people.


1 This was particularly good at the AHS, and was likely to be highly variable across general practices.



1 This was largely informal through referrals, information sharing and collaborative promotion.


1 There was limited evidence of patient-centred planning across providers at baseline.

Informal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., referral protocols, service directories, cross-agency awareness training) are in place.

1 There was some limited evidence of informal mechanisms and practices facilitated by individual relationships across key providers.

Formal mechanisms or practices that support service coordination and patient-centred planning




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Assessment

and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co location of services, and shared information systems and joint planning) are in place.Services within the system are complementary and there is no duplication.

2 Services were considered complementary given the size and diversity of the Aboriginal and Torres Strait Islander population in the area.



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Changes expected to occur as a result of the ICDP at baselineTwo organisations in the area had ICDP funding at baseline. The DoGP was funded for an IHPO and ATSIOW, and the AHS was set to receive funding for a RTSHLT in early 2012. The NACCHO Affiliate is also located within the area and was set to receive funding for an IHPO. At baseline, it was reasonable to expect that the following changes would occur as a result of the ICDP: The AHS reported that preventive and population-based health programs had

not previously been an area of focus for the organisation, but that was likely to change with the commencement of the RTSHLT.

The PIP Indigenous Health Incentive was expected to be a significant income generator for the AHS, and the PBS Co-payment measure was expected to free up funds that were being used to pay for patient medication. The AHS was planning to re-invest these funds into enhancing the administrative capacity of the organisation and implementing some quality use of medications initiatives to complement the PBS co-payment measure.

Registrations for the PIP Indigenous Health Incentive in the mainstream sector were expected to be supported through active promotion by the IHPO employed by the Medicare Local.

It was hoped that ICDP would facilitate greater coordination of care, particularly between the AHS and general practices such as GP practices.

3.2.2 Site two at finalAt the final stage, the key characteristics of the site remained much the same, that is: the site supported a relatively small but geographically disbursed Aboriginal

and Torres Strait Islander community; there were a broad range of services available at the site, including an AHS

which was considered to be a service hub for the local community; the site was not identified as a district of workforce shortage for general

practice; and the level of cultural appropriateness in mainstream organisations varied

greatly from largely culturally appropriate to other (particularly within some geographic pockets) general practices that were not considered culturally appropriate at all.

At baseline, the main ICDP funded mainstream organisation was a DoGP. In November 2011, this DoGP merged with three other DoGPs to form the Medicare Local.

ICDP workforce investment and activity at site two Table 3030 below shows the number of ICDP workers allocated to the Medicare Local by final stage.


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Table 30: ICDP workforce allocation (FTE) within site two, 2012-13 (various dates).74

Position

ACCHO

ML

Total allocation

CC - 175 1IHPO - 2 2ATSIOW

- 176 1

TAW 2 - 2HLW 3 - 3RTC 1 - 1Total 6 - 10

ICDP workforce investment in the Medicare LocalCtG Team (IHPO and ATSIOW): There are two IHPOs and one ATSIOW working at the Medicare Local. The two IHPOs work closely with the ATSIOW, however, on the final round site visit the ATSIOW role had recently been re-filled after a period of vacancy (over three months) and, as such, the new worker did not yet have an established pattern of working. The two IHPOs have quite different but complementary roles. One is focused largely on building relationships, networking, completing practice and health service visits, and representing the organisation on a number of key Aboriginal and Torres Strait Islander Health committees. The other IHPO comes from a background in research and working with a state-based preventive health research organisation and, as such, his focus is on the development of policies and protocols for the Healthy Lifestyle Teams, AHSs, and mainstream health services to build culturally appropriate ‘best practice’ models of service delivery in the region. The two IHPOs had not had an issue with duplication of work roles or confusion; however, it is noted that the IHPO focused on policies and practices had been in the role less than six months. There was an acknowledgment that the role would likely change in the future but this was yet to be confirmed. Care Coordinator: A Care Coordinator was engaged during 2013, shortly after the site consultations concluded in April. While there were plans for the Care Coordinator to work closely with the ATSIOW and AHS, it is unclear how this was translated in practice.

74 Workforce data provided by the former Department of Health and Ageing. Note there are different datasets for each worker type, and each provide point in time snapshots at dates within 2012-13. 75 The Care Coordinator was engaged after the evaluation consultation process.76 The ATSIOW was based within the AHS one day per week.


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ICDP workforce investment in the AHSRTSHLT: The RTSHLT comprises one RTC, two TAWs and three HLWs. There had been little turnover in the team since commencement over 18 months though, at the time of the final round site visit, the RTC had just left. Recruitment of the team was reported as straightforward, with a number people applying; however a key difference in this region was the predominance of younger male workers. It was reported that, while males were not specifically targeted during employment, they were the only people to apply. The RTSHLT had an initial focus on implementing and supporting ‘smoke-free’ workplaces in the AHS and ACCHO, which was expanding into the ACCHO sector in the region. A number of the RTSHLT members had also assisted with implementing healthy catering policies for the AHS and ACCHO, which were noted as successful now that all meetings and community events focussed on providing healthy food choices. A secondary focus, which was expanding at the time of the final round visits, was providing information packs on smoking cessation at community events, and junior sporting events in particular such as basketball and football carnivals. Three of the team members had achieved their certificate in personal training and two were introducing exercise programs for the local Aboriginal men’s groups. The training for all team workers was developed with the previous RTC such that each team member had an individual training plan they were working through with annual appraisals.

Impact of the ICDPEach of the changes expected to occur as result of ICDP investment were found to have occurred at the final stage. These expected changes were: additional healthy lifestyle programs; increased cultural competency of practices; increase in PIP Indigenous Health Incentive practice participation; improved access to pharmaceuticals; improved access to primary health care; and improved cultural appropriateness across all patient pathways within the site.Overall, the key changes as a result of ICDP investment at this site, with reference to the conceptual framework, were: system capacity: an expanded health workforce including health promotion

and prevention workers; access: improved access to services, including specialists and allied health

services, in a culturally appropriate local setting; and service coordination: increased information sharing, including ongoing

reporting and discussion between the Medicare Local and local general


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practices about the progress of individual Aboriginal and Torres Strait Islander patients with a chronic disease.


Changes to system capacitySince 2009, the services provided to Aboriginal and Torres Strait Islander patients through the Medicare Local expanded as illustrated in Table 31 below.

Table 31: Summary of chronic disease-related services provided by the Medicare Local in site two at 2009 and 2013.77

Service provided by the ML 2009 2013Care coordination No YesSupplementary Services No YesCulturally appropriate support during mainstream appointments

No Yes

Support with booking appointments and filling scripts

No Yes

Guidance with locating culturally appropriate health care

No Yes

There was no change in the range of chronic disease related services being provided by the AHS between baseline and final stages, although overall the FTE increased. See the tables below.78

Table 32: Summary of chronic disease related services provided by the AHS in site two for 2009-10 and 2011-12.79


Yes Yes

Chronic disease management groups Yes YesTobacco use treatment and/or prevention groups No Yes

77 Based on information gathered online.78 Note there are a number of limitations with this data that are explored in the appendices.79 Based on OSR data, provided by the former Department of Health and Ageing.


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Table 33: Summary of AHS service provision in site two for 2009-10 and 2011-12.80

Indicator 2009-10 2011-12 % ChangeNumber of FTE positions on staff 104.30 118.60 13.71%Number of FTE Doctors providing services

8.10 5.80 -28.40%

Number of FTE Medical specialists and allied health professionals providing services

6.40 14.30 123.44%

Total number of episodes of care 38,420 48,707 26.78%Aboriginal or Torres Strait Islander patient episodes of care as a proportion of total episodes of care

89.77% 92.39% 2.92%

Total number of clients 4,933 5,256 6.55%Aboriginal or Torres Strait Islander clients as a proportion of total clients

83.24% 87.42% 5.02%

All of the ICDP investments in site two represented new Aboriginal and Torres Strait Islander-specific health services that align closely with community need. The Medicare Local IHPO sits on a number of local Aboriginal Health advisory

committees, including one connected to a major teaching hospital. Stakeholder and Aboriginal and Torres Strait Islander community consultation

and needs analysis was conducted by the Medicare Local. Partnerships were formed between the Medicare Local CtG team, ACCHO,

ICDP staff, QUIT and local secondary schools to deliver programs to prevent the uptake of smoking and promote smoking cessation amongst young people within the site.

The development of the RTSHLT has grown the site capacity to promote preventive health and education directly to community members through a number of different pathways, such as community events, directly at AHSs and to individual community members.

The Medicare Local CtG Team coordinated a forum for Aboriginal and Torres Strait Islander staff working within the area in 2013.

The ICDP has also increased the number of mainstream health services offering care to Aboriginal and Torres Strait Islander people in the region. One example is the community health service at the site providing specific sessions for Aboriginal and Torres Strait Islander patients with a chronic disease, where visiting USOAP specialists also held regular sessions and an ATSIOW was available to attend with patients.

80 ibid.84


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Changes to accessibilityThe ICDP has increased both physical and cultural accessibility of services in the region.The Medicare Local employed two ICDP workers, an IHPO and an ATSIOW, with cultural ties to the community.

‘Having Aboriginal people with ties to the local community is really important. It gives the Medicare Local some credibility. It has been a really positive experience.’81

Culturally appropriate mainstream and AHS health services were promoted by the Medicare Local in partnership with the AHS. A one hour weekly program was produced and aired on local Aboriginal and Torres Strait Islander community radio to promote general practices for Aboriginal and Torres Strait Islanders. Social media was also used by the Medicare Local to engage the local Aboriginal and Torres Strait Islander community.The Medicare Local incorporated culturally appropriate policies across the organisation. This included the: development and implementation of a Reconciliation Action Plan (RAP); development of an Aboriginal and Torres Strait Islander Community and Stakeholder communication and engagement strategy; delivery of cultural awareness training for Medicare Local staff; development of culturally safe working environments for Aboriginal and Torres Strait Islander staff; and the inclusion of culturally appropriate health requirements within all Medicare Local funded organisation contracts, Medicare Local delivered or funded programs, and future requests for tenders and expressions of interest.

‘Through our partnership with QUIT we have been able to implement evidenced based policies…we know what works but it is good for people to understand why we are implementing policies.’82

The Medicare Local IHPO promoted PIP Indigenous Health Incentive registration, online cultural awareness training and Health Checks to local GPs and practice nurses. This included encouraging general practices to actively recall their Aboriginal and Torres Strait Islander patients and offer them Health Checks, as and when appropriate.The ATSIOW actively engaged with the Aboriginal and Torres Strait Islander community within the site. This included the promotion of culturally appropriate health services available within the site at many local Aboriginal and Torres Strait Islander and other community events.

‘GPs have made changes, to make their practice more culturally safe, even to their waiting rooms like adding the flag, it makes a difference.’83

The ATSIOW provided advocacy to patients visiting mainstream health services, collected prescriptions from the pharmacy on behalf of patients, engaged GPs in

81 Consultation with the Medicare Local, site two. 2013.82 Consultation with IHPO, site two. 2013.83 ibid.


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the PIP Indigenous Health Program, and provided information to the Medicare Local regarding which GPs were currently registered in PIP.A service directory listing culturally appropriate health services was developed by the ATSIOW for distribution throughout the community. This included the names and contact details of all local GPs that were registered for the PIP Indigenous Health Incentive, local AHLOs, and culturally appropriate health programs, specialists and pharmacists.

‘Before people didn’t know where they could go (for culturally appropriate health services) and we couldn’t tell them, now we can let people know…giving people that information is empowering.’84

Table 3434 provides an overview of the proportion of the estimated Aboriginal and Torres Strait Islander population with a chronic disease registered for the PIP Indigenous Health Incentive at this site.

Table 34: Site population PIP Indigenous Health Incentive statistics.Statistic FigureAboriginal and/or Torres Strait Islander population85 3,302Estimated number of Aboriginal and/or Torres Strait Islander population with a chronic disease86

905

Patients (EverIHI)87,88 411Estimated proportion of Aboriginal and Torres Strait Islander people estimated to have a chronic disease who are PIP Indigenous Health Incentive registered

45.4%

The number of Health Assessments provided to EverIHI patients and the number of providers of Health Assessments increased during the evaluation period, although this was a relatively small effect considering the size of the community. There was a small increase in number of providers undertaking Health Assessments after the baseline year but this also was not material. There was no meaningful change in the number of Health Assessments per provider between 2010 and 2012 (). There was only a moderate increase in the number of Health Assessments per 100 EverIHI patients between baseline and 2012 (Table 36).This is perhaps associated with relatively low engagement of general practices in PIP Indigenous Health Incentive when compared to site one (which is also an urban site). This is supported by the lower reported rate of participation

84 ibid.85 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra.86 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.87 MBS data supplied by the former Department of Health and Ageing, 2013.88 This is defined as the maximum number of patients that have registered and received at least one MBS service in a given six month period. As such, the Patients (EverIHI) values may not always match the numbers in the proceeding tables.


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in cultural awareness training and other information gathered from Medicare Local staff. There was a more substantial, increase in allied health follow-up services after June 2010 (Table 37). This was also true for the number of allied health follow up services per 100 EverIHI patients between baseline and 2012. Similarly the number of allied health follow up services per 100 Health Assessments had also increased between baseline and 2012 (Table 37). There was evidence of neither increased specialist attendances nor increased numbers of specialists after the baseline period (Table 39), nor GP attendances, numbers of GPs serving the Aboriginal and Torres Strait Islander community nor average attendances per GP (Table 40). There was essentially no change in the number of GP attendances per 100 EverIHI between baseline and 2012 (Table 40). There was a noticeable increase in pathology tests for EverIHI patients between the baseline year and 2012 although the relatively small numbers of patients involved meant this change was not large in absolute terms.

Table 35. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012.Statistic 2009-

102012

EverIHI patients 406 385GP attendances 4,427 4,21


1,090 1,096

These findings suggest there may have been changes in the patient journey for EverIHI patients at site two. The changes appear as increased proportions of EverIHI patients undergoing a Health Assessment. This may be leading to increased use of pathology testing and of follow-up allied health services for assessed patients. There is no evidence of increased referral to specialists. The small size of the observed changes indicate that any such changes in patient journeys are very limited at site two.

Table 36. Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012.89

Statistic 2009-10

2012

EverIHI patients 406 385Health assessments 64 79Health assessments per 100 EverIHI

16 21

89 MBS data supplied by the former Department of Health and Ageing, 2013.87


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Table 37. Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site two in 2009-10 (baseline period) and calendar year 2012.90

Statistic 2009-10

2012

EverIHI patients 406 385Allied health follow-up items 38 125Follow-ups per 100 EverIHI 9 32Follow-ups per 100 Health assessments

15 41

Table 38. Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012.91

Statistic 2009-10

2012

EverIHI patients 406 385Specialist attendances 56 56Specialist attendances per 100 EverIHI

14 15

90 ibid.91 ibid.


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Table 39: Numbers of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments92 and average Health Assessments per provider at site two, by six month period, 2007 to 2012.93

Six months ending

Aboriginal and Torres Strait Islander Health Assessments


Health assessments per provider

June 2007 15 7 2.1December 2007

18 7 2.6

June 2008 18 5 3.6December 2008

20 7 2.9

June 2009 35 12 2.9December 2009

33 13 2.5

June 2010 31 7 4.4December 2010

21 12 1.8

June 2011 38 12 3.2December 2011

39 16 2.4

June 2012 50 20 2.5December 2012

29 19 1.5

Table 40. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site two in 2009-10 (baseline period) and calendar year 2012.94

Statistic 2009-10

2012



1,090 1,096



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Table 41. Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.95

Statistic 2009-10

2012

EverIHI patients 406 385Pathology services 2,420 2,72


596 707

Table 42: Numbers of allied health follow up services96 for EverIHI patients at site two, by six month period, 2007 to 2012.97

Six months ending



95 ibid.96 MBS subgroup M03—Allied Health Services plus MBS subgroup M11--Allied Health Services For Indigenous Australians Who Have Had A Health Check.97 MBS data supplied by the former Department of Health and Ageing, 2013.


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Table 43: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site two, by six month period, 2007 to 2012.98

Six months ending

Attendances Providers Attendances per provider


98 ibid.91


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Table 4: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site two, by six month period, 2007 to 2012.99

Six months ending



Table 5: Numbers of pathology services for EverIHI patients at site two, by six month period, 2007 to 2012.Six months ending

Pathology services

June 2007 1,009December 2007 887June 2008 1,197December 2008 1,045June 2009 1,233December 2009 1,208June 2010 1,212December 2010 1,287June 2011 1,362December 2011 1,327June 2012 1,325December 2012 1,398

99 ibid.92


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Table 6: Number of PBS scripts dispensed to EverCtG patients by six month period, site two, 2007 to 2012.100

Six months ending

Scripts


Interestingly, while the relative growth rate in PBS scripts dispensed to EverCtG patients between 2007 and 2009-10 was comparable with that for the other urban site one, the absolute numbers were substantially smaller than at that site (Table 646). Further, while that growth accelerated after 2009-10, the level of acceleration was not as great as at site one. Moreover, there was an atypical reversal of growth in the six months ending December 2012.

Changes to service coordinationThe CtG team developed formal working relationships with key primary and acute health stakeholders, as well as the ACCHO and AHS that operated within the site. This relationship allowed information about PIP Indigenous Health Incentive registered GPs to be shared and disseminated to the Aboriginal and Torres Strait Islander community.A partnership was also formed between the Medicare Local, AHS and the Pharmacy Guild to disseminate information about CtG scripts to local pharmacies and Aboriginal and Torres Strait Islander community members.The pharmacist at the AHS developed information for patients to take to community pharmacies that may not be familiar with CtG scripts, in order to improve their access to subsidised medication scripts.The IHPO worked with AHLOs and Aboriginal Community Workers to create culturally appropriate pathways and post-acute after care through the exchange of referral data. 100 Pharmaceutical Benefits Scheme data. Provided to KPMG by the Department of Health, 2013.


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‘We were surprised that even this year (2013) many outlying community pharmacists didn’t know about CtG scripts, after a number of patients came back saying they had to pay for (these) scripts still we decided to develop a note for them to take with our contact details, it seems to have helped.’101

Impacts of ICDP on patient experienceImportant changes to the patient journey were noted: Improved identification of Aboriginal and Torres Strait Islander patients at

general practices. The ICDP has led to the employment of IHPOs and ATSIOWs, who have worked closely with a number of practices in the area to develop a list of those that are culturally safe and allow patients to identify as Aboriginal and/or Torres Strait Islander in a safe environment. The ICDP workers, however, noted there were still ‘pockets’ of general practices that had not engaged with the ICDP.

Improved cultural awareness in some general practices. Through the work and cultural awareness training provided by the IHPO at the site, a number of GPs had signed on for PIP-Indigenous Health Incentive and were writing CtG scripts and referring Aboriginal and Torres Strait Islander patients to specialists engaged under USOAP. Over 20 practices had completed the cultural awareness training in the region, showing a strong level of interest in building cultural competency.

Reducing the cost of medicines. The ICDP measure to reduce the co-payment for PBS scripts was reported as having reduced a significant barrier for Aboriginal and Torres Strait Islander patients who needed often expensive medication for the treatment of chronic conditions. It was noted, however, that while many pharmacies were familiar with CtG scripts (possibly due to the volume), there were still a number, particularly in outlying areas, which did not have familiarity with the scheme. Of note, a simple workaround of taking a note with a brief explanation of CtG and the contact details of the pharmacist at the AHS to the community pharmacist appears to have reduced this issue for some patients.

‘My little brother needed medication which was going to cost my mother $160, I knew she couldn’t afford it. Because I knew about the CtG scripts I could get the medicine for him, otherwise I don’t know what we would have done.’102

Enhanced access to specialist care. This was achieved primarily through the USOAP program, which reduced the financial barrier and ensured that services were geographically and culturally accessible for Aboriginal and Torres Strait Islander patients.

101 Consultation with IHPO, site two. 2013.102 Consultation with community member, site two. 2013.


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Ongoing challenges relevant to ICDP A number of key barriers and gaps were evident at site two at final stage. These included the following, as outlined below. Aboriginal and Torres Strait Islander patient identification was an ongoing

issue. This was being addressed by the Medicare Local through GPs, and community education and promotion.

Engagement of general practices appears to have peaked yet there remains a number of practices that are not PIP Indigenous Health Incentive registered or actively involved, even though they are seeing Aboriginal and Torres Strait Islander patients. This remains a gap the CtG team are focused on addressing in the future.

Delayed central approval of the Medicare Local CtG plan slowed its implementation; however, this is now being implemented.

There remained a reticence for people to change lifestyle habits such as eating and smoking; while the RTSHLT reported engaging and educating a number of people at community events and through initiatives held at the ACCHO and AHS, the degree of actual behaviour change was unknown.

3.2.3 Final assessment against the conceptual framework at site two Table 747, Table 848 and Table 949 below draw together the information presented above about site two at the final stage. Against conceptual framework domains characteristic, this table provides: the rating the evaluators gave the site at baseline103; the rating the evaluators gave the site at final stage104; the key changes observed; and what these changes appear to be attributable to.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.Figure 3 and Figure 4 provide a visual representation of the findings within this chapter as at baseline and as at the time of the final evaluation. Each figure is presented as a systems map which details, on a single page, the health services provided within the community, primary, secondary and tertiary sectors within the site. Each patient services map includes the:103 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory. 104 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory/moderate change from a low base. 3= notable change from baseline.


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AHS and mainstream services/supports located within the site; ICDP staff and programs (post-ICDP map only); linkages between services, where these are in place; and identified facilitators and barriers to patient accessibility to these services.


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Base

line

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ng

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Key changes Changes attributable to


2 2 This site had a good level of access to infrastructure to deliver health services at baseline, and this remains the case at the final stage.

There was a noted increase to one outlying health service, which had added Aboriginal and Torres Strait Islander-specific sessions provided by the USOAP specialists; however, this was limited to one geographic pocket of the site.


2 2 The workforce was assessed as being largely sufficient at baseline; however, ICDP has strengthened the workforce further through recruitment of additional workers.

An additional nine staff were recruited and located within both the mainstream sector and AHS sector.


2 2 Needs assessment was performed by Medicare Local as a part of their ICDP funding. These were considered by the Medicare Local particularly in: building cultural awareness within general practices; adapting Quality Improvement frameworks to include CtG focus, and community engagement and education programs. There was also greater awareness of services available to Aboriginal and Torres Strait Islander people.

The ICDP staff at the Medicare Local developed an extensive Closing the Gap needs assessment in June 2012. This has been used as a central point of reference for services in the region.


2 2 The practice IT systems in the region were quite robust at the beginning and remained so at final visit. While the systems are unchanged, there is now an increased level of reporting of PENCAT data. For example, by the Medicare Local back to individual general practices, to give them data on how many

This improvement relates to the proactive work of the CtG team at the Medicare Local developing more specific reports for Aboriginal and Torres Strait Islander patients in the region.

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Characteristics

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ting


registered patients they had for the month, the number of Health Assessments completed and other detailed clinical data.


2 3 There is very strong leadership and commitment to addressing the cultural needs of Aboriginal and Torres Strait Islander clients and workers within the Medicare Local. This is done through: RAP, the incorporation of Aboriginal and Torres Strait Islander into all contracts and programs, delivering strong Aboriginal and Torres Strait Islander messages to the mainstream and Aboriginal and Torres Strait Islander communities, and a strong desire to form working relationships with Aboriginal and Torres Strait Islander organisations.

The number of networks, Memorandum of Understanding (MOUs) and partnerships in place is evidence of strong leadership at the level of the Medicare Local, AHS, ACCHO and beyond. For example, one Acute Health Service board in the region had appointed an AHS CEO.

Table 8: Assessment of change against the conceptual framework – domain 2: access.Characteristics

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Services are geographically accessible to patients or support physical access e.g., through provision of transport or outreach

1 2 The AHS provided transport to clients so that they could access services. While this was not a part of the ICDP, the service remained in place throughout the ICDP evaluation. The local ATSIOW augmented this service by attending appointments with individuals, mainly in mainstream settings.

The ATSIOW role augmented the existing transport service provided by the AHS.USOAP allowed services to be delivered in a geographically and culturally accessible location

Services are financially 1 2 Financial barriers to access have been addressed ICDP programs have reduced financial barriers

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accessible to patients through the SS funds and USOAP both of which have assisted patients to access specialist and allied health services, and medical aids, and CtG scripts which have reduced the financial barrier to accessing medicines.

(CtG scripts, CCSS, USOAP)

Services target (and are tailored to) multiple patient groups

2 2 Culturally appropriate services were provided across the service system (community, primary, secondary and tertiary care). These have increased since baseline. Some general practices were more aware of the cultural needs of Aboriginal and Torres Strait Islander patients. Supports and advocacy were provided to Aboriginal and Torres Strait Islander patients by the Medicare Local. This included making and attending appointments with patients. A number of stakeholders, including patients, also noted improved access to medication.

The IHPO directly educated and provided cultural awareness training to GPs.The ATSIOW provided culturally appropriate support.CtG scripts, which were promoted by the IHPO in partnership with the Pharmacy Guild.

There are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments and decision making

1 2 There were improved mechanisms within the general practices to improve culturally appropriate patient pathways through all levels of health services; primary, secondary and tertiary care.

The ICDP funded IHPO within the Medicare Local liaised with GPs, the AHLO and Aboriginal Social Workers to improve the cultural appropriateness of patient care pathways within the site for Aboriginal and Torres Strait Islander patients.The ATSIOW had a key role with patient support and advocacy in general practices.

Services take steps to ensure a culturally appropriate

1 2 The Medicare Local promoted cultural awareness training to its staff and GPs within the site. Supports

The IHPO conducted cultural awareness training.

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Characteristics

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ting


environment for patients AND/OR…

and advocacy were provided to Aboriginal and Torres Strait Islander patients by the Medicare Local. This included making and attending appointments with patients.

The ATSIOW had a key role with patient support and advocacy in general practices.

There is receptivity to change within organisations to make services more culturally appropriate for patients

1 2 The Medicare Local actioned a RAP and ensured that culturally appropriate health items were incorporated as core requirements of funding agreements for all Medicare Local funded organisations, as well as in Medicare Local delivered programs, requests for tenders and expressions of interest.

The ICDP funded positions, particularly the IHPO, facilitated these changes.


2 2 The Medicare Local now employs Aboriginal and Torres Strait Islander staff who are local community members.

The ICDP funded IHPO and ATSIOW both identify as Aboriginal, and thus their employment provides legitimacy to the Medicare Local role in Aboriginal and Torres Strait Islander health.

Cultural awareness training and immersion is available to the health workforce

1 2 The Medicare Local promoted cultural awareness training to its staff and GPs within the site. 20 practices engaged in training during the evaluation period.

The ICDP funded IHPO promoted direct and online cultural awareness training to GPs.

100



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1 2 Relationships between the AHS and Medicare Local were strengthened since baseline. There was evidence of information sharing, networking and corporation between organisations.

The IHPO and ATSIOW engaged with the AHS, and CEO-level interaction was occurring at the site.


1 1 The level of patient-centred planning remained the same as at baseline. It was expected to increase with the pending employment of a Care Coordinator.

The level of planning involving multiple providers appeared to remain the same through the evaluation period.

Informal mechanisms or practices that support service coordination and patient-centred planning and care delivery (e.g., referral protocols, service directories, cross-agency awareness training) are in place.

1 2 A service directory for Aboriginal and Torres Strait Islander patients was developed, identifying PIP Indigenous Health Incentive registered practices and pharmacies that had produced CtG items. This had taken considerable time and persistence to develop, largely due to the challenges of overcoming practice ‘privacy issues’ and concerns about how the information was to be used.

The service referral directory was developed by ATSIOW.

Formal mechanisms or practices that support service coordination and patient-centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, shared information systems and joint planning) are in place.

1 1 There were no notable changes in service coordination from baseline to final. This was noted as a considerable challenge, particularly due to the large number of mainstream health services available and the difficulty for individual patients to navigate. There was an expectation that the CCSS worker employed would start to address these issues.

CCSS had not yet been implemented in the region.

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2 2 The CtG team worked hard to ensure that there was minimal duplication and all services were complementary and in partnership with the AHS, such as in not duplicating the transport services the AHS already had available.

The development of ICDP services following a comprehensive community needs assessment appears to have been a key element to not duplicating existing services.

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Site two (SSE) pre ICDP – patient journey map

Com

mun

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cond

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Terti

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Prevention Ongoing treatment and support Diagnosis and treatment


ICDP linkage

Non-ICDP linkage



Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

Ongoing access

*Barrier expected to be reduced by

ICDP staff/program

Ongoingaccess

Referral Referral

Referral

Scripts

Ongoing access

Referral

Referral

Ongoing access

Ongoing access

Community Health Cenrre

Transport provided

Housing

Transport provided

IHS visiting specialists and allied health

professionals

IHS

Long waiting times

PHC visiting/local specialists

Community are reluctant to identify as Aboriginal due to

experiences of racism*

Links with AHLO

Variable costs


professionals

Negative peer

pressure discouraging

exerciseLocal Pharmacies

Links with IHS

AHLO

GP Practices


GP Practices

Employment

Lack of transport

Not culturally appropriate*

Sport/exercise clubs and facilities

Social Stressors

Welfare

Lack of timely

transport*

Lack of transport

Good quality care

Lack of interest in Aboriginal healthProvision of

transport

Transport provided by HIS

Local hospital (including dialysis)

Lack of availability


Local Pharmacies

Variable costs

IHS IHS based

healthy lifestyle programs

Limited reach into wider community

Lack of cultural awareness*

Lack of awareness relating to

the need for identification of Aboriginal

patients*

Support Services

Knowledge of IHS

programs

Outreach

Link with IHS

Education

Ongoing access

Acute Care focus*

Access to medication (QUMAX)

Lack of clarity about

accessibility*

Low awareness of programs in wider community

Cost of medications*

Figure 3: Patient service map site two: Baseline. Source: KPMG.103



June 2014

Site two (SSE) with ICDP – patient journey map

Com

mun

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cond

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Terti

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ICDP linkage

Non-ICDP linkage



ICDP staff/program

Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

*ICDP facilitator

Ongoing access

Barrier reduced by ICDP staff/program

Ongoingaccess

Referral

Referral

Referral

Referral

Scripts

Ongoing access

Accessand

Coordination

Referral

Referral

Ongoing access

Accessand

Coordination

Ongoing access

Ongoing access

Community Health Cenrre

Transport provided

Improved follow-up for CDSM*

Housing

Transport provided*Transport provided


professionals

PIP-IHI registered practices*

Improved follow-up for

CDSM*

USOAP

IHS

Long waiting times


Community are reluctant to identify as Aboriginal due to

experiences of racism

USOAP

Links with AHLO

Care Coordination*

Variable costs

Improved cultural

awareness*

Transport provided*


professionals

Negative peer

pressure discouraging

exercise

ML Care Coordinator

Difficulty identifying

PIP-IHI registered practices

Local Pharmacies

Advocacy for CtG scripts*

Links with ICDP

services*

Links with IHS

ML ATSIOW (C3)

AHLO

Lack of CtG script awareness

GP Practices


ML IHPO (C3)

GP Practices

Employment

Lack of transport

Not culturally

appropriate

Sport/exercise clubs and facilities

Social Stressors

Welfare

Lack of timely

transport

Lack of transport

Transport provided*

Good quality care

Lack of interest in Aboriginal healthProvision of

transport

Transport provided by HIS




Local Pharmacies

Variable costs

Community do not value identifying as

Aboriginal

IHS

Reduced costs of medication*

CtG scripts*Transport provided*

Lack of knowledge of CtG Scripts

IHS based healthy lifestyle

programs

Limited reach into wider community

Lack of cultural awareness

Lack of awareness relating to

the need for identification of Aboriginal

patients

Support Services

Knowledge of IHS

programs

ATSIOW (C2)

Improved access*

Outreach

Link with IHS

Education

Ongoing access

Acute Care focus

Collaboration with ATSIOW and CC*

Access to medication (QUMAX)

Lack of clarity about accissibility

Figure 4: Patient service map site two: Final. Source: KPMG.104



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3.3 Site three (Inner regional)3.3.1 Site three at baselineSite three is an inner regional site, and includes a regional centre (referred to as the town) as well as a nearby discrete Aboriginal community. The town is just under 70 kilometres from the state capital city. The Aboriginal community, which was once a mission, had a population of around 170 people at baseline (as reported by the local Aboriginal Corporation). The town is relatively well serviced, and people from surrounding areas travel to the town, to access services. The people who live in the Aboriginal community have limited choices in terms of primary and secondary health care services, and no access to tertiary services. Although proximity to the state capital means travel to access secondary and tertiary services is manageable for some Aboriginal and Torres Strait Islander people, there are significant barriers for many in accessing this travel (e.g., costs, no private transport) Service coordination is impacted by some poor relationships within the service system, and limited information sharing.Table 50 provides summary statistics for site three, covering the local population profile, participation in the PIP Indigenous Health Incentive and conduct of Health Assessments.


Indicator StatisticEstimate Resident Population (2011 Census) 25,263Aboriginal/Torres Strait Islander population (2011 Census) 1,309Proportion of Population identifying as Aboriginal and Torres Strait Islander

5.2%


379


29%


20

Site three includes two hubs, a hospital, a small number of GPs and pharmacies, an AHS, 10 community health centers, a DoGP with an Aboriginal and Torres Strait Islander health program and a general practice with Aboriginal and Torres Strait Islander staff. In this site, there are no after-hours services.



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System capacity

General practice systemAt baseline, the town had two key private, general practices, and a community health centre providing GP services. The community health centre is situated on the hospital grounds and was providing GPs, nursing, social and emotional wellbeing services and an Aboriginal Primary Health Care Unit at baseline. There were no afterhours general practice services.The local DoGP was running a state funded program at baseline that provided outreach health checks within the town (from two GPs) at the Aboriginal community through the community health service, and in three smaller towns in the region. As part of this initiative, a mobile health van offering health checks and nursing services was also being run. All of the primary health care services in the town were operating on electronic patient information and practice management systems at baseline. There was still some paper based record keeping, however, e.g., health check information. The DoGP had strongly promoted the Medical Director clinical information system and many practices were moving to this system. The DoGP was collecting the following types of data at baseline: demographics (age, gender); living arrangements; Aboriginal and Torres Strait Islander status/ethnic background; service data (number of clients receiving service and occasions of service); referral data (new referrals); and activity data. None of this data was being shared with other agencies at baseline. Data was being used mostly for reporting to funders, performance management and internal governance/quality improvement. It was also (less frequently) being used for needs assessment and service planning, and measuring client/consumer outcomes. The community health centre had done some (limited) monitoring and evaluation of its Aboriginal and Torres Strait Islander health programs. A number of specialist and allied health services were available in the town in permanent (number unknown) and visiting (at three services) capacities. Visiting services were available through the hospital and the community health centre (podiatry, dietetics, physiotherapy, diabetes education) and the largest GP practice within the town.In the town there is a hospital offering a number of services including emergency, visiting specialist services, palliative care, geriatrics, obstetrics, assessment and dialysis. Only eight dialysis chairs were available at baseline. There was funding for an AHLO at the local hospital, however, this position was vacant at baseline. There were a number of community pharmacies available within the town with varied opening hours, however, there were no afterhours services available at all, and no pharmacy services in the Aboriginal community.There were two main private dentist services at the site – one at the largest GP practice in the town, and another private dentist clinic. Dental services are available to children through two government-run school-based services.


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There were various mainstream social programs running in the town at baseline, such as many sport opportunities including a ‘Rage Cage’ sport centre, youth groups incorporating physical activity, the Headspace program, and a Parental and Community Engagement (PaCE) program.

Aboriginal and Torres Strait Islander service systemAt baseline there was a community controlled Aboriginal corporation providing health care in the Aboriginal community, including a weekly visiting GP clinic and visiting allied health providers including a dietician, podiatrist, and diabetes educator. Lack of physical space, however, meant that only limited services could be provided in one session. No OATSIH Services Report data is available for this site. Another local Aboriginal and Torres Strait Islander community service was running a mobile outreach assistance van, which provided services around the whole region. This service was targeted towards people with substance misuse and mental health issues. There were a number of additional community programs running in the town at baseline, for example: a monthly Aboriginal and Torres Strait Islander women’s group that involved meetings and physical activity; and a junior development program focusing on encouraging Aboriginal and Torres Strait Islander children to play sport for a healthy life.

Access Community members generally reported that general practices were providing services in culturally appropriate ways. All general practices had local Aboriginal staff, and had historically been providing services to large numbers of Aboriginal and Torres Strait Islander clients. There were no afterhours general practice services.There were also specific Aboriginal and Torres Strait Islander focused services being provided from these centres, such as an Aboriginal health check clinic. The majority of the local GP staff had done Aboriginal and Torres Strait Islander identification training through the DoGP. All staff at the community health centre had done cultural competency training. Some community members said that local pharmacies could improve their cultural competency.

Service coordinationInformation provided by the DoGP at baseline suggests that service coordination - both across the service system and between the Division and other services with which clients are shared, was working moderately well, as the table below shows.At baseline, service providers reported that there were poor relationships between some services within the region (namely between the key non-government and government primary health care services working within Aboriginal and Torres Strait Islander primary health care), and that limited information sharing between these services was a significant issue impacting


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service coordination. No formal practices supporting service coordination were reported.

Table 51: Assessment provided by Division of General Practice with regard to service coordination.106

Partnership area

Rating out of 10

Networking 8Service coordination

6

Cooperation 5Collaboration 5

Patient experience There were two distinct but interrelated patient journeys at this site – the journey for Aboriginal and Torres Strait Islander people living in the town, and the journey for people living in the Aboriginal community. In the town, there was relatively easy access to health services, sport infrastructure, fresh food, and community services including transport, whereas from surrounding towns access was very restricted. Despite this, barriers to accessing services existed across the site including the costs associated with health care, lack of access to transport and the lack of fully serviced AHS in the community. In addition, service coordination across services was perceived as poor.

PreventionThe key issues identified by community members in relation to prevention were: Many preventive services are mainstream, and focussed on younger people

or elders. Difficulties accessing fresh fruit and vegetables for some people. Drug and alcohol use impacting peoples’ overall health and wellbeing.In the town, there are lots of options to access fresh and healthy food, with a range of supermarkets, restaurants and fruit and vegetable shops. There are also, however, a lot of take away shops, and people are in the habit of eating junk food.

‘[Main town] has lots of variety’107

Access to fresh food is an issue in the Aboriginal community, as the community only has a small store that does not stock fresh food, and the closest supermarket is over an hour drive away. There is space for a community garden, however to date no one has taken responsibility for setting it up and running it. 106 Where 10 is very effective service coordination and 0 is ineffective service coordination. Based on information collected during site visits. 107 Consultation with community member, site two. 2013.


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As a result, community members have to do one large food shop, and the fresh food often does not last.

‘People won’t commit. They go on holidays, or away somewhere, and it (the community garden) will die. No one can look after it all the time.’108

‘It’s hard to always have the fresh food because people drop in and expect a feed.’109

There are lots of opportunities to play sport in the town, and there are a number of exercise and healthy lifestyle programs available; however most are mainstream, and many are sport focussed and/or targeted at youth. In the Aboriginal community there are also opportunities for physical activity – there is a free gym, and there are local spots for fishing and swimming. However, there is a perception that although there are lots of programs and activities for young people and elders, other adults miss out.There is some traditional food gathering across the region – mostly fishing, and some hunting for Kangaroo and other meat. However, for most people this is only a small proportion of their diet.Although smoking, alcohol and drug taking has decreased in recently years, it is still a problem in the town and in the Aboriginal community. This leads to health problems, but also mental health problems; for example, there has been a rise in psychosis according to one community member. Many of the Aboriginal Health Workers who work in the town and provide outreach in the Aboriginal community are smokers. People perceive these people as hypocrites when they provide anti-smoking messages, and it sets a bad example for young people.

Diagnosis and treatment The key issues identified by community members in relation to diagnosis and treatment were: Costs associated with health care, and transport to health care, which impacts

on access to health care. Inconsistencies in the availability of health services between the town and the

Aboriginal community.In the town, the majority of the community access general practices in private practice and are satisfied with the services they provide, and consider them culturally appropriate. There is also a perception amongst service providers that people do not like to access government run services, including the community health centre, which may explain the high rates of access to private GPs. However, the cost of GP appointments can influence where people access primary health care. Most of the private GPs do not bulk bill so if someone cannot afford the appointment fee, they must go to the local community health centre. 108 ibid.109 ibid.


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In the Aboriginal community, some people use the visiting GP services at the Aboriginal Corporation, while others travel to local towns for primary health care services. The visiting health services in the Aboriginal Corporation can be unreliable and are not available frequently. It can also be difficult to get an appointment because there is high demand but only one three hour clinic a week.

‘If someone gets sick and it’s not a clinic day they’re in trouble.’110

The cost of medication, particularly where multiple medications are required, is a significant barrier to accessing medication for many people. Although people in town can usually get to a pharmacy relatively easily to purchase required medicines, in the Aboriginal community there is no pharmacy and people have to travel into one of the towns for medicines. These factors combined can result in non-compliance with medication. Generally, most specialist services are available, however, they can be non-accessible for a range of reasons. One is cost – although there is funding available to cover the gap in specialist fees, people are required to pay the gap up front, and many people do not have hundreds of dollars on hand for this. Other key barriers are transport and availability of some health care services. Many people do not have access to private transport. In the town, the hospital and other clinics that provide visiting specialist services are accessible via public transport. However, if people have to travel to the town for these services, difficulties are often experienced. Cost and transport barriers are also applicable to accessing private dentists and AHPs.

‘There’s no transport here [Aboriginal community], and most people don’t drive.’111

In some instances community members have to travel to the city to access specialist services (e.g. orthopaedic), and in these cases costs and transport barriers are increased. Isolated Patients Travel and Accommodation Assistance Scheme funding is available to support people to travel to access health care, and is used quite frequently by community members who are aware of it and are linked in with local services. However, this funding is often available to get to the appointment, but not to get home, so people can be stuck in the city when they are their most vulnerable.For dialysis, there are three options – home dialysis, local dialysis at the hospital, and city hospital dialysis. The option selected is largely based on availability and/or severity of condition. Only a small number of community members use home dialysis, which involves outreach support from hospital nurses. High demand means that the local dialysis beds are not often free. This results in people having to travel frequently or in some cases re-locate to the city.

‘[With home dialysis] the infections put people off.’112



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Community members identified a number of additional barriers associated with accessing primary health care, both in the town and the Aboriginal community: many community members are reluctant to access primary health care

because they are worried about ‘what they will find out’ (i.e. a diagnosis); there is a level of stigma associated with accessing general practices,

particularly government services as noted above, and some concerns about cultural safety –a small number of community members said general practices are unwelcoming;

it can be difficult to get an appointment with a doctor due to high demand. This is particularly relevant in the Aboriginal community as noted above; and

in the most accessed general practice, patients cannot see a GP if they have an outstanding bill. This is seen to lead to reduced access to the service.

The table below shows professional attendances and pathology services in 2009/20 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.






3,181 1,845 379 8.4 4.9

Ongoing treatment and supportThe key issues identified by community members in relation to ongoing treatment and support were cost and transport issues. GPs, AHWs and nurses working in local practices, and local specialists, often refer patients to community support services once diagnosed with a chronic disease. In the town, these include community groups such as men’s, women’s and elders groups, a local wellbeing group, social and emotional wellbeing programs, and broader social support such as housing and legal rights. Access to ongoing specialist care and primary health care (i.e. for chronic disease maintenance) can be impacted by transport and cost barriers.


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Baseline assessmentTable 53 below draws together the information presented above about site three at the final stage. Against conceptual framework domain characteristics, this table provides the rating113 the evaluators gave the site at baseline.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.



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Table 53: Assessment against the conceptual framework.Domains Characteristics Ratin

gAssessment

System capacity


1 There was a lack of infrastructure in Aboriginal community. There were some gaps in service delivery in relation to specialists and AHPs.


1 There were some local Aboriginal staff working in mainstream health services and the AHS. Some of these were funded through the state Closing the Gap funding, with this ICDP funding leading to more Aboriginal and Torres Strait Islander staff being employed in the DoGP and the AHS.


1 There were a range of services available, but some only in a visiting capacity. Permanent services are in high demand. There was demand for additional Aboriginal and Torres Strait Islander-specific services.


1 Primary health care services’ practice management appeared sound, based on consultations. There was inadequate information about monitoring and evaluation more broadly. The majority of GPs reported that they were using clinical information systems like Medical Director.


2 Services appeared to be committed to Aboriginal and Torres Strait Islander health; the DoGP, AHS and local general practices embraced the state Closing the Gap funding.


1 Services were accessible in the town, but not from the Aboriginal community. Transport was a significant barrier. There was some outreach (albeit limited and unreliable) to the Aboriginal and Torres Strait Islander community.

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June 2014


Assessment

Services are financially accessible to patients. 1 The cost of health care itself, and the cost of transport to access services, was identified as a major barrier by many community members. Although some supports are in place, such as the limited services provided through the Aboriginal corporation and the Isolated Patients Travel and Accommodation Assistance Scheme, these were seen to be insufficient to meet the needs of patients.


2 The DoGP, AHS and general practices targeted Aboriginal and Torres Strait Islander people broadly through their services, as well as offering sub group targeted programs such as for pregnant women and people with chronic disease.


- There was inadequate information to assess this.


2 Services appeared to provide a welcoming environment, with posters and local artwork in waiting rooms, and Aboriginal and Torres Strait Islander staff to greet patients.


2 As noted above, local services embraced the state Closing the Gap program. Further local GPs signed up to the PIP Indigenous Health Incentive. Together, these examples suggest receptivity.


2 There were local Aboriginal and Torres Strait Islander staff working within mainstream health services and the AHS though the state Closing the Gap program.

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June 2014


Assessment


2 Local GPs, Community Health staff completed cultural awareness training.



0 Some issues around relationships and information sharing were reported.


1 The issues between services limited this from occurring between some services. There were also some positive relationships, however, focusing on patient care.


0 Relationship issues impacted upon information sharing and referrals.

Formal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, shared information systems and joint planning) are in place.

0 No formal processes identified.


1 There did not appear to be duplication, particularly because (as reported by the DoGP and the AHS) patients who attended the AHS were not likely to attend the general practices and vice versa.

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Changes expected to occur as a result of the ICDP at baselineTwo organisations in the area were set to receive ICDP funding at baseline. One was a DoGP and one was a government-run AHS. The following benefits were expected: The RTSHLT, which will sit in the AHS, was expected to provide additional

healthy lifestyle activities in the region; although these (unlike many of the existing health lifestyle activities) will be targeted to Aboriginal and Torres Strait Islander people. This RTSHLT will also provide Aboriginal and Torres Strait Islander tackling smoking activities that will be new in the area. The main way this team was expected to address gaps is by providing Aboriginal and Torres Strait Islander specific services.

As in many areas, the PBS co-payment and PIP Indigenous Health Incentive measures were expected to reduce the financial barriers to accessing medicines and assist Aboriginal and Torres Strait Islander people to address their chronic disease. At the time of the baseline consultations, the AHS and the two major general practices in the main town were planning to register for the PIP Indigenous Health Incentive and provide CtG scripts. However, these measures are likely to have less impact for the Aboriginal community, as, although the visiting GP was planning to register for the PIP Indigenous Health Incentive as well, meaning they could prescribe CtG scripts, there was no pharmacy in the Aboriginal community. Other contextual factors, such as the limited availability of a GP and lack of transport from this Aboriginal community, were expected to result in the ICDP having reduced impact.

The ATSIOW within the DoGP was expected to address what were reported as significant local transport gaps, and the CCSS Program was expected to supplement the existing funded transport for Aboriginal and Torres Strait Islander people, which provided for trips to the city for health care. The Care Coordinator was also expected to reduce the financial barriers to accessing specialist and allied health services through use of SS funds, leading to increased access. The ATSIOW and Care Coordinator were also expected to address some of the barriers associated with limited access to health care (e.g., by encouraging people to make attend appointments). The IHPO was expected to address barriers relating to the cultural inappropriateness of some general practices in site three (as reported by community members).

3.3.2 Site three at finalThe key characteristics of the town remained similar between baseline and final stages in terms of the spread of the population and the number and nature of primary, secondary and tertiary services and sporting and exercise opportunities. Key changes at this site included: construction of a new AHS in the Aboriginal community, this was nearing

completion in early 2013;


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additional, chronic disease related services as the hospital, such as more dialysis beds; and

a new large discount pharmacy in the town, located centrally within a main shopping centre.

At baseline, the DoGP was an independent NGO with core funding. At final stage, the DoGP had become a GP Network affiliated with the Medicare Local, a separate organisation. The GP Network was not receiving any core funding and relied on funding being allocated by the Medicare Local at final stage.A state funded closing the gap program had been operating in this site since baseline. This provides funding for AHWs whose role is to perform health checks and link patients in with GPs for more comprehensive screening (e.g., Health Assessments).

ICDP workforce investment and activity at site threeAt site three, a total of 9.5 FTE ICDP workers were allocated across the DoGP (now GP Network affiliated with the Medicare Local) and the AHS by final stage, as Table54 below shows.

Table54 ICDP workforce allocation (FTE) within site three, 2012-13 (various dates).114

Position

AHS

GP Network

Total Allocation

CC 0 1.0 1.0IHPO 0 1.0 1.0ATSIOW

0 2.5 2.5

RTC 1 0.0 1.0TAW 2 0.0 2.0HLW 2 0.0 2.0Total 5 4.5 9.5

ICDP workforce investment in the AHSRTSHLT: A RTSHLT at this site has been in place since 2011, although as at early 2013 only one of the original team members remained: the HLW. The team is comprised of one RTC, one TAW and one HLW. A TAW had recently left for another role at final stage, thus a TAW position was unfilled. The AHS had used the funding to establish a core team in the town, and put workers in place across the region. Thus there were four 0.5 FTE TAW positions in

114 Workforce data provided by the former Department of Health and Ageing. Note there are different datasets for each worker type, and each provide point in time snapshots at dates within 2012-13.


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‘outreach locations’ between 45 minutes and four hours drive away at final stage. The two newer workers in the core team (RTC and TAW) had been employed for around six months as at early 2013.The rollout of activities by the team was delayed due to the staff turnover. The team started a social marketing campaign in 2011 targeting smoking, but this was on hold to at final stage to allow the RTC and TAW to up skill adequately to provide smoking cessation supports. The HLW activities, which started in 2011, include cooking and exercise groups (such as walking groups) and were being provided in the town and as outreach to the Aboriginal community at final stage. While these continued through the staff turnover, there have been periods where the HLW has been the only team members, and the RTSHLT’s ability to reach the target population has been limited because of this.The location of the team within a government service has led to two key issues: from the perspective of the team, the requirement to comply with

government approval processes limit their ability to attend training and events and purchase equipment they need, and this has further delayed their service delivery;

from the perspective of the team and community members, being located in a government-run AHS has limited target group engagement with the team. There are many people in the community who do not like accessing a government-run service and thus are not exposed to the team.

As at early 2013, the team was providing only a small number of healthy lifestyle group activities.The AHS had recently received funding for MSOAP-ICD program at the final stage consultations, but this program was not yet operating.

ICDP workforce investment in the GP NetworkCtG team (ATSIOWs, Care Coordinator and IHPO): Like in site one, the ATSIOWs, Care Coordinator and IHPO at the GP Network work closely together as part of a CtG team, but unlike the team in site one, the state-funded AHWs are integrated into this team with the ICDP workers. This team has also experienced some turnover of staff. The Care Coordinator and one AHW have been part of the team since 2011, but at early 2013 two new ATSIOWs and a new AHW had recently been employed. The IHPO position was not filled at the time the final stage consultations were conducted. The focus of the team is on working collaboratively to meet the needs of the local Aboriginal and Torres Strait Islander community. Clients are referred to the team through GPs, self-referrals or by the workers identifying them as ‘in need’. Once a referral is received, team members visit the client to do an informal needs assessment and they are then linked with the appropriate team member and services. This may include the AHWs who can provide a health check.


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The role of the ATSIOWs within the team structure was focused on providing transport, information and encouraging people to attend their appointments. It also includes linking them in with services and supports to address their broader issues such as housing issues. The ATSIOWs are often the initial point of contact for patients, and make referrals to the Care Coordinator as appropriate. Patients reported in final stage consultations that they feel like they can approach any of the workers, and they will ensure they are linked with the supports they require. The role of the Care Coordinator was centred on facilitating access to specialists. In the most part this requires SS funds to be accessed and used to pay for transport, the cost of appointments and medical aids. The IHPO role has been filled by three different workers, each of whom have worked with the two local GP practices to ensure they are PIP Indigenous Health Incentive registered and comply with the cultural awareness training requirement. The IHPOs have also encouraged the practices to identify Aboriginal and Torres Strait Islander patients and prescribe CtG scripts. The IHPO had a role in establishing an Aboriginal and Torres Strait Islander clinic at one of the practices, and the Network staff used to provide services from this clinic (e.g., the AHW provided health checks and the ATSIOWs met with patients after their appointment to discuss how they would meet their health needs). The clinic was staffed by AHS AHWs and a nurse at final stage.

Impact of the ICDPEach of the changes expected to occur as result of ICDP investment were found to have occurred at the final stage. These expected changes were: Additional healthy lifestyle and tackling smoking programs Improved access to pharmaceuticals Improved access to primary health care Increase in PIP Indigenous Health Incentive practice participation Additional Aboriginal and Torres Strait Islander specific programs Reduced financial barriers to accessing health care Improved access to specialist and allied health services Transport difficulties addressedIn addition to these expected changes identified at baseline, several other impacts were also observed. Overall, the key changes as a result of ICDP investment at this site, with reference to the conceptual framework, were: system capacity: increased number of Aboriginal and Torres Strait Islander

health workers, and new health facilities and services in the Aboriginal community;

access: improvements in the accessibility of some services, namely access to local specialists and allied health services through CCSS funding, and enhanced cultural appropriateness of primary health care through Aboriginal


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and Torres Strait Islander specific clinics and programs being provided from general practices; and

service coordination: improved working relationships between the AHS mainstream organisations, including better information sharing between ICDP workers.


Changes to system capacityThe employment of ICDP workers and other workers through the state-funded closing the gap program has resulted in increased workforce capacity in site three. The ICDP funding led to three additional Aboriginal and Torres Strait Islander

staff being employed in the GP Network and three additional Aboriginal and Torres Strait Islander health staff being employed in the AHS as at early 2013.

The state-funded closing the gap program led to an additional six Aboriginal and Torres Strait Islander health staff being employed across the GP Network and the AHS.

This has been an important shift for patients in site three. At baseline, community focus group participants discussed how the lack of Aboriginal and Torres Strait Islander workers in the region contributed to limited cultural appropriateness within local services. Like in many other sites, the ICDP (as well as the state-funded closing the gap program) has led to general practices offering Aboriginal and Torres Strait Islander health programs that were not provided in the past, for example: the CtG program is the first Aboriginal and Torres Strait Islander health

program in the GP Network and the team are the first Aboriginal and Torres Strait Islander staff within this organisation; and

both of the GP practices in the town were registered for the PIP Indigenous Health Incentive at final stage, and one clinic was providing a weekly Aboriginal and Torres Strait Islander health clinic.

Unlike some other sites, many patients still perceived they had limited choice in where they accessed primary health care at final stage. Both of the general practice do not bulk bill, if patients require free GP services the only places they can access this are: the community health centre (which houses the AHS) similar to baseline,

many Aboriginal and Torres Strait Islander people in this region still did not feel comfortable accessing government-run services such as this AHS at final stage; and

through the weekly Aboriginal and Torres Strait Islander health clinic at one of the GP practices, which was in high demand at final stage.


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There is no OSR data for this site, thus data on the range of services provided by the AHS and whether this has changed over time, is not available.

Changes to accessibilityThe ICDP has increased the accessibility of services in the region and reduced the reliance on visiting services: The availability of SS funds resulted in increased access to required services

within the region. Through accessing SS funds, the Care Coordinator has purchased local health care services, namely specialist and allied health appointments, for patients with chronic disease. At baseline patients reported that:- they could not afford to pay for local private appointments;- there were long wait lists for public services available through the hospital;

and- they were reluctant to travel to the capital city to access public services,

even though the waiting lists were shorter. The commencement of MSOAP-ICD will further increase access to specialist

and allied health services. This funding is held by the AHS. The ATSIOWs and SS funds contributed to improved physical accessibility by

supporting transport for patients within and outside of the region. Prior to these programs patients relied on a state-funded patient assisted transport scheme and community transport, which were infrequent and sometimes left patients stranded in the capital city for extended periods.

The cultural appropriateness of general practices has been enhanced through Aboriginal and Torres Strait Islander specific programs and services being made available in mainstream settings, namely: the weekly Aboriginal and Torres Strait Islander health clinic at one of the GP

practices in the town. Through this clinic Aboriginal and Torres Strait Islander people have access to free primary health care, some of which is provided by Aboriginal and Torres Strait Islander workers; and

the CtG program provided through the GP Network.The number of PIP Indigenous Health Incentive registered patients is illustrated in the table below. As at 2011, the number of Aboriginal and Torres Strait Islander people estimated to have chronic disease was approximately the same as the number of people who were EverIHI in 2011 at site three.


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Table 55.Site population PIP Indigenous Health Incentive statistics.Statistic FigureAboriginal and/or Torres Strait Islander population115 1,309Estimated number of Aboriginal and/or Torres Strait Islander population with a chronic disease116

347


100%

There was growth in the number of Health Assessments provided to EverIHI patients after the baseline year of 2009-10 at site three, driven by an increase in the number of providers providing Health Assessments (Table 56). There was no meaningful change in the number of Health Assessments per provider between baseline period and 2012. There was a substantial increase in the number of Health Assessments per 100 EverIHI patients between the baseline period and 2012. There was suggestion of growth in the numbers of allied health follow-up services after June 2010, however it was erratic and not large in size (Table 58). The change in the number of allied health follow-up services may be due to an additional one or two patients receiving these services. This is consistent with the observed fall in the follow-ups per 100 Health assessments between baseline period and 2012 (Table 59).There was no evidence of increased attendances at specialists and these actually fell below baseline levels in 2012 (Table 60). This was also the case for specialist attendances per 100 EverIHI patients (Table 61).Numbers of GP attendances were essentially flat throughout the period from 2007 to 2012, while the numbers of GPs serving the Aboriginal and Torres Strait Islander community grew somewhat during 2011 and 2012 (Table 62 ). GP attendances per 100 EverIHI patients remained unchanged between the baseline period and 2012 (Table 63).There was no meaningful change in trends for pathology tests after the baseline year (Table 64). However, there was a slight increase in pathology services per 100 EverIHI patients (Table 65).These findings suggest little change in the patient journey for EverIHI patients at site three were found through this MBS data analysis. That change was limited to

115 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra.116 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.117MBS data supplied by the former Department of Health and Ageing, 2013. 118 This is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period. As such the Patients (EverIHI) values may not always match the numbers in the proceeding tables.


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increased monitoring or screening through health assessments and did not translate into increased delivery of secondary services, such as allied health follow up, pathology testing and specialist attendances.

Table 56: Numbers of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments and average Health Assessments per provider119, site three, by six month period, 2007 to 2012.120

Six months ending



Health Assessments per provider


Table 57. Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site three in 2009-10 (baseline period) and calendar year 2012.121

Statistic 2009-10

2012


6 30



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Table 58: Numbers of allied health follow up services122 for EverIHI patients at site three, by six month period, 2007 to 2012.123

Six months ending



Table 59. Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site three in 2009-10 (baseline period) and calendar year 2012.124

Statistic 2009-10

2012


30 9

122 MBS subgroup M03—Allied Health Services plus MBS subgroup M11--Allied Health Services For Indigenous Australians Who Have Had A Health Check.123 MBS data supplied by the former Department of Health and Ageing, 2013.124 ibid.


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Table 60: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site three, by six month period, 2007 to 2012.125

Six months ending



Table 61. Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site three in 2009-10 (baseline period) and calendar year 2012.126

Statistic 2009-10

2012


26 16

125 ibid.126 ibid.


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Table 62: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site three, by six month period, 2007 to 2012.127

Six months ending



Table 63. Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site three in 2009-10 (baseline period) and calendar year 2012.128

Statistic 2009-10

2012



892 889

127 ibid.128 ibid.


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Table 64: Numbers of pathology services for EverIHI patients at site three, by six month period, 2007 to 2012.129

Six months ending

Pathology services

June 2007 778December 2007 1,063June 2008 1,014December 2008 1,140June 2009 1,044December 2009 1,180June 2010 982December 2010 1,133June 2011 1,193December 2011 1,260June 2012 1,094December 2012 1,178

Table 65. Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.130

Statistic 2009-10

2012



627 668

Table 10 below shows the number of PBS scripts dispensed to EverCtG patients between 2007 and 2012. It shows that in site three, like most other sites, there was consistent, high growth in PBS scripts dispensed to EverCtG patients leading up to June 2010 followed by a substantial increase in growth post 2010.The number of scripts dispensed in site three was less than for regional site four perhaps reflecting population differences (site three has a smaller population than site four) but more than for regional site five which has a much larger population than site three. There were no medicine subsidy programs operating at this site.

129 ibid.130 ibid.


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Table 10: Number of PBS scripts dispensed to EverCtG patients by six month period, site three, 2007 to 2012.131

Six months ending

Scripts


Patients engaged in community focus groups reported that, while some of the GP practice staff are culturally aware and treat Aboriginal and Torres Strait Islander patients with respect, many practice staff exhibit culturally inappropriate practices, particularly reception staff, such as asking private questions in front of other people and making stereotype-based assumptions, such as that all Aboriginal and Torres Strait Islander people smoke. This may have limited service access in site three for some people.

Changes to service coordinationAt baseline, there were poor relationships between the different parts of the service system. These were caused by perceived competition for patients and funding, and led to a fractured service system. For patients, this meant services did not talk to each other. It also resulted in some duplicative service delivery, for example, service providers discussed patients being provided with the same or similar services at both the AHS and general practice. The key change in site three in this area was improved relationships between the AHS and mainstream sector organisations (the GP Network and local GP practices). According to senior organisational representatives from the GP Network and the AHS at final stage: more referrals were made between services, for example the RTSHLT

referring some patients to the general practices, recognising that some are not comfortable accessing the AHS GPs;



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organisations were participating in joint population health planning meetings; and

there was more informal discussion and information sharing than in the past, including between ICDP workers when they have clients in common, or when it was identified that clients could benefit from the other organisation’s programs.

The allocation of different ICDP funding across these two services may have reduced the likelihood of duplication. Each service has a very clear role; the AHSs’ is health promotion and prevention (through the RTSHLT) and the GP Network’s is supporting access to services and care coordination (through ATSIOWs, CCSS and IHPOs). Finally, the ICDP and state-funded closing the gap program were considered complementary by service providers consulted during final stage consultations. This is because the state-funded closing the gap positions are clinically focused and the ICDP positions are not and thus these workers have been able to work together to meet a broader range of patient needs. One of the most significant gaps reported at baseline for site three was the limited availability of health services in the Aboriginal community. The construction of a new health centre will provide new infrastructure from which services can be delivered. Although this is not ICDP funded, it will facilitate access to ICDP workers because workers will have a space from which to deliver outreach programs. As at early 2013, both the GP Network and AHS were planning to increase their delivery of outreach services to this community post the completion of the health centre.

Impact of the ICDP on the patient experience The patient journey has primarily been enhanced through the employment of local Aboriginal and Torres Strait Islander people. Patients feel comfortable approaching these workers for information and support, which has led to improved knowledge of the health care system and increased access to services. The supports available through the ICDP workers have addressed the major barriers to access, namely; transport, affordability and limited services and outreach in some areas. Important changes to the patient journey were noted: Improved awareness of services to address health needs, and how to

navigate the health system. The ICDP led to appointment of dedicated workers (ATSIOWs and a Care Coordinator) to work with patients to address these barriers – this has resulted in improved understanding of the services available in the health care system and how to access these amongst local Aboriginal and Torres Strait Islander people. The branding of the ICDP workers as a ‘CtG team’ has provided Aboriginal and Torres Strait Islander community members with a single point of contact for information and support.


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‘I used to go to the local doctor but the doctor didn’t really explain what my medicines were for. Sometimes I went to the pharmacy to get my medicines, but because I didn’t know what they were for I didn’t take them or forgot to take them. Now that [Care Coordinator] is around, they can come to the doctors with me and explain what the medicine is for. They also remind me to take my medicines which is good.’132

Enhancing the understanding local mainstream providers have of Aboriginal and Torres Strait Islander health. The ICDP workers in the GP Network have promoted ICDP programs such as the PIP Indigenous Health Incentive and PBS Co-payment as well as Aboriginal and Torres Strait Islander specific MBS items to local GPs. Through this, they have tried to explain the importance of comprehensive care for Aboriginal and Torres Strait Islander people with chronic disease. The IHPO also provided cultural awareness training to practice staff. The establishment of the Aboriginal and Torres Strait Islander weekly health clinic, which ICDP workers have been involved in, has made it easier for GPs to become involved in Aboriginal and Torres Strait Islander health initiatives, as the AHWs have taken on initial PIP Indigenous Health Incentive care plan and 715 paperwork, so the GPs only have to confirm the AHWs’ opinion and sign off on these items.Finally, the ATSIOWs and IHPO have worked with pharmacies to ensure their awareness of CtG scripts and the importance of regular medicine access and compliance for Aboriginal and Torres Strait Islander people with chronic disease.

‘The staff members at the local clinic don’t take us seriously. The reception staff are very rude. Also, the GP makes assumptions that you are a smoker and have diabetes. Since [IHPO] I have heard that the doctor is more understanding. But the receptionists are still rude and they also still don’t do CtG scripts so I don’t go there.’133

Reducing the cost of health care. As in many sites, the SS funds and CtG scripts initiatives have reduced this significant barrier to services for Aboriginal and Torres Strait Islander people and commented that this led to increased access to specialist services and medicines.

Improving access to local health care. As noted above, the ICDP has facilitated easier access to specialist and allied health services locally.

‘The local doctor is the easiest to get to, but they don’t bulk bill so I don’t go there. The other clinic is very far away and I wasn’t able to get there. We have a bus service sometimes but it doesn’t work for Aboriginal people because you can’t take your family and it puts a lot of pressure on us. Since

132 True to life vignette. These vignettes present de-identified examples that are very similar to situations observed during the evaluation activities. 133 ibid.


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the [ATSIOW] started, they can provide money and drive people around. It is really good that I can see the free doctor now.’134

The impacts of the RTSHLT have been restricted to increasing awareness of the harms of smoking and the importance of healthy eating, due to the limited and interrupted service delivery from this team.

Ongoing challenges related to ICDP A number of key gaps and challenges were evident at site three at final stage. These included: Ongoing culturally inappropriate practices within general practices. The GP

Network staff reported that, while some GPs within the two local practices are receptive to changing the way they work with Aboriginal and Torres Strait Islander patients, there are many staff, particularly reception staff, who do not see the need for, or value of, participating in cultural awareness training and treating Aboriginal and Torres Strait Islander patients differently to other patients. Further, the general practices do not bulk bill Aboriginal and Torres Strait Islander patients outside of the Aboriginal and Torres Strait Islander health clinic, which is seen as a significant access barrier.

Geographically dispersed and mobile population – the town is a central point in the region for service delivery. This means many people from surrounding areas come to the town to access health care. ICDP workers reported difficulties in engaging with and providing follow up services to transient patients.

Limited motivation for change amongst many Aboriginal and Torres Strait Islander people. Local providers and community members reported that there are still many patients who are not engaging with health care because of lack of motivation. This made changes difficult to achieve.

Access within the Aboriginal community. While the new health centre will allow more outreach service provision in this location, no health providers will be permanently located in the community. There will continue to be no pharmacy and limited access to fresh, healthy food.

Some services still not available within the region. One example is dialysis; despite recent increases, there were still only a limited number of chairs at the local hospital at final stage.

134 ibid. 131


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3.3.3 Final assessmentTable 11, Table 128 and Table 69 below draw together the information presented above about site three at the final stage. Against the conceptual framework domains characteristic, this table provides: the rating the evaluators gave the site at baseline135; the rating the evaluators gave the site at final stage136; the key changes observed; and what these changes appear to be attributable to.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.Figure 5 and Figure 6 below provide a visual representation of the findings within this chapter as at baseline and as at the time of the final evaluation. Each figure is presented as a systems map which details, on a single page, the health services provided within the community, primary, secondary and tertiary sectors within the site. Each patient services map includes the: AHS and mainstream services/supports located within the site; ICDP staff and programs (post-ICDP map only); linkages between services, where these are in place; and identified facilitators and barriers to patient accessibility to these services.



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Table 11: Assessment of change against the conceptual framework – domain 1: system capacity. Characteristics

Base

line

rati

ng

Fina

l ra

ting

Key changes Changes attributable to…


1 1 In early 2013, a new health centre was being built in the Aboriginal community, addressing a significant gap apparent at baseline. In the town, the office space for ICDP workers was inadequate in both the Medicare Local and AHS, and access to venues for events and activities remains limited.

Funding external to the ICDP enabled the new health centre to be built.


1 3 The number of Aboriginal and Torres Strait Islander health workers in the town is much higher than at baseline. Additional outreach is also being provided to the Aboriginal and Torres Strait Islander community by the ATSIOWs, Care Coordinator and the RTSHLT. The state-funded AHWs work closely with the ATSIOWs; enhancing workforce capacity. Some recruitment and retention issues (e.g., high turnover) have negatively impacted workforce capacity.

The ICDP has created 9.5 FTE additional positions including 4.5 FTE within the mainstream sector. The state-funded closing the gap program has also contributed a number of additional FTE.


1 2 The permanent services available through the ICDP address a previous barrier identified at baseline, which was heavy reliance on visiting services. Through CCSS, there is enhanced access to private specialists using the SS funds. Access to primary health care is still restricted due to no local GPs bulk billing. An AHW clinic which the ATSIOW and Care Coordinator are linked with provides free appointments once a week, going some way towards mitigating this. Transport and access to

The ICDP has funded many of these new services. The state-funded closing the gap program has contributed as well.

133



June 2014

Characteristics

Base

line

rati

ng

Fina

l ra

ting


primary and secondary health care locally, were significant gaps at baseline. The ATSIOWs now provide transport.


1 3 At baseline, the practice management and clinical information systems in services within this region appeared sound. The Medicare Local and AHS both reported improvements in the quality of data collected and information sharing in early 2013.

The improvements were attributed to ease of information sharing using the data systems linked to the CCSS Program (MMEx) and state-funded closing the gap program utilise. Workers reported that transition to Medicare Locals led to an increased focus on monitoring activities and reporting.


2 2 Services appear to be committed to Aboriginal and Torres Strait Islander health; the DoGP, AHS and local general practices have embraced the state closing the gap funding. The AHS reports that while the funding has increased activity within Aboriginal and Torres Strait Islander health, general practices’ level of interest is linked to the availability of funding and incentives.

Both the ICDP and the state-funded closing the gap program have raised the profile of Aboriginal and Torres Strait Islander health through injection of funding and rollout of new programs and services. However, the state-funded closing the gap program was in place at baseline, and thus there was not significant change in this area.


Base

line

rati

ng

Fina

l ra

ting


Services are geographically accessible to patients, or support physical access

1 In the town, the services were generally geographically accessible at baseline, but in the Aboriginal community, they were very inaccessible.

Much of the outreach provided is undertaken by ICDP workers, however some state-funded AHW outreach is also occurring. The transport

134



June 2014

Characteristics

Base

line

rati

ng

Fina

l ra

ting


e.g., through provision of transport or outreach

This has changed with an increase in the level of outreach provided to the Aboriginal community. ICDP workers have increased access through making appointments for patients and facilitating their access to services, for example through providing transport.

support, and other supports for access are provided solely by ICDP workers.

Services are financially accessible to patients

1 2 Financial barriers to access have been addressed through the SS funds which have assisted patients to access specialist and allied health services, and medical aids, and CtG scripts which have reduced the financial barrier to accessing medicines. The transport assistance provided through ICDP (ATSIOWs and SS funds) has also helped people access affordable care options.

ICDP programs have reduced financial barriers (CtG scripts, CCSS).

Services target (and are tailored to) multiple patient groups

2 2 At baseline, the Medicare Local (then DoGP), AHS and general practices targeted Aboriginal and Torres Strait Islander people broadly through their services, as well as offering sub-group targeted programs such as for pregnant women and people with chronic disease. This did not change between the baseline and final stages.

No changes

There are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments

- 1 At baseline, there was inadequate information to assess this. One practice out of town provides free transport and bulk billing for Aboriginal and Torres Strait Islander clients, and a practice in the town offers a weekly Aboriginal and Torres Strait Islander health clinic.

Neither of these initiatives is ICDP funded.

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June 2014

Characteristics

Base

line

rati

ng

Fina

l ra

ting


and decision makingServices take steps to ensure a culturally appropriate environment for patients AND/OR…

2 1137 In early 2013, patients and health providers reported that practices are generally not culturally appropriate. Services appear to provide a welcoming environment, with posters and local artwork in waiting rooms, and Aboriginal and Torres Strait Islander staff to greet patients. However, consultations with patients suggest practice staff are rude, and this can limit access. There is also a perception from community members that the AHS is not culturally appropriate because it is a government service, and is not ‘Aboriginal friendly’.

The PIP Indigenous Health Incentive does not seem to have enhanced the cultural appropriateness of care at the local general practices.

There is receptivity to change within organisations to make services more culturally appropriate for patients

2 1138 As noted above, local services have embraced the state Closing the Gap program. Further local GPs have signed up to the PIP Indigenous Health Incentive. Together these examples may suggest receptivity. However, patient reports suggest cultural appropriateness is not embedded within local practices

As above, the PIP Indigenous Health Incentive does not seem to have enhanced the cultural appropriateness of care at the local general practices.


2 3 At baseline, the state-funded AHWs were local Aboriginal people. All of the ICDP staff are Aboriginal and Torres Strait Islander and all but one, the Care Coordinator, are local. The Care Coordinator has built strong relationships with patients, and patients report she is approachable and her services are highly

The main changes in this area are as a result of ICDP funded positions.

137 Note this rating was decreased, due to more information becoming available. 138 Note this rating was decreased, due to more information becoming available.

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Characteristics

Base

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ng

Fina

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valuable.Cultural awareness training and immersion is available to the health workforce

2 2 Local GPs, Medicare Local and AHS staff have done cultural awareness training.

The PIP Indigenous Health Incentive has provided impetus for this in local practices.

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0 3 There have been significant improvements in this area since baseline. Information is shared through complementary data systems, as noted above.

This has been driven by the requirement for Medicare Locals to work collaboratively with AHSs, by the efforts of individuals, and somewhat through the turnover of ICDP staff e.g., an IHPO previously employed by a DoGP became and RTC, and this reduced the barriers to communication between ICDP workers across the two ICDP funded organisations.


1 2 As at baseline, there were some positive relationships focusing on patient care. The sharing of information between organisations for common patients has led to improvements in patient focus.

The positive relationships were driven by individuals. As above, the improvements in information sharing are attributable to ease of using the data systems linked to the CCSS Program (MMEx) and state-funded closing the gap program utilise.


0 3 The relationship issues impacting information sharing and referrals have improved, thus likely facilitating significant enhancements in this area.

As above, this has been driven by the requirement for Medicare Locals to work collaboratively with AHSs, by the efforts of individuals, and somewhat through the turnover of ICDP staff.

Formal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., dedicated case

0 0 No formal processes were identified at baseline or at the final stage.

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management resources, availability of brokerage funds, co-location of services, shared information systems and joint planning) are in place.Services within the system are complementary and there is no duplication.

1 2 The finding at baseline remains relevant: there does not appear to be duplication, particularly because (as reported by the DoGP and the AHS) patients who attend the AHS are not likely to attend the general practices and vice versa.

The ICDP and the state-funded closing the gap positions are seen as complementary because the AHWs are clinical, whereas the ATSIOWs who they work closely with are non-clinical.


1 1 In early 2013, a new health centre was being built in the Aboriginal community, addressing a significant gap apparent at baseline. In the town, the office space for ICDP workers was inadequate in both the Medicare Local and AHS, and access to venues for events and activities remains limited.

Funding external to the ICDP enabled the new health centre to be built.


1 3 The number of Aboriginal and Torres Strait Islander health workers in the town is much higher than at baseline. Additional outreach is also being provided to the Aboriginal and Torres Strait Islander community by the ATSIOWs, Care Coordinator and the RTSHLT. The state-funded AHWs work closely with the ATSIOWs; enhancing workforce capacity. Some recruitment and retention issues (e.g., high turnover) have negatively impacted workforce capacity.

The ICDP has created 9.5 FTE additional positions including 4.5 FTE within the mainstream sector. The state-funded closing the gap program has also contributed a number of additional FTE.

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1 2 The permanent services available through the ICDP address a previous barrier identified at baseline, which was heavy reliance on visiting services. Through CCSS, there is enhanced access to private specialists using the SS funds. Access to primary health care is still restricted due to no local GPs bulk billing. An AHW clinic which the ATSIOW and Care Coordinator are linked with provides free appointments once a week, going some way towards mitigating this. Transport and access to primary and secondary health care locally, were significant gaps at baseline. The ATSIOWs now provide transport.

The ICDP has funded many of these new services. The state-funded closing the gap program has contributed as well.


1 3 At baseline, the practice management and clinical information systems in services within this region appeared sound. The Medicare Local and AHS both reported improvements in the quality of data collected and information sharing in early 2013.

The improvements were attributed to ease of information sharing using the data systems linked to the CCSS Program (MMEx) and state-funded closing the gap program utilise. Workers reported that transition to Medicare Locals led to an increased focus on monitoring activities and reporting.


2 2 Services appear to be committed to Aboriginal and Torres Strait Islander health; the DoGP, AHS and local general practices have embraced the state closing the gap funding. The AHS reports that while the funding has increased activity within Aboriginal and Torres Strait Islander health, general practices’ level of interest is

Both the ICDP and the state-funded closing the gap program have raised the profile of Aboriginal and Torres Strait Islander health through injection of funding and rollout of new programs and services. However, the state-funded closing the gap program was in place at

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linked to the availability of funding and incentives.

baseline, and thus there was not significant change in this area.

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Site three (SSE) pre ICDP – patient journey map

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ICDP linkage

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Facilitator

Barrier

HEAL

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Ongoing access

Ongoing access

Ongoing access

Referral

Ongoing access

Referral

Referral

Ongoing access

Lack of targeting to community

need


Cooperation with IHS

Healthy lifestyle programs/events

Barring of patients

Difficulty accessing other practices

Poor attendance

Support Services

Local PharmaciesLow

awareness*

Co-location of some staff at IHS

GP Practices

Subsidised medication

(IHS patients)

IHS

IHS diabetes prevention program IHS

Knowledge of IHS programs

Supportive environment

Lack of engagement*

Social Stressors

Lack of Patient privacy

Local Pharmacies

City based hospital

specialists

GP consulting in mainstream and IHS

GP Practices


Hospital based AHPs

Limited engagement with non-service users

Awareness of risk factors



City based hospital

specialists


Cultural awareness

Patient privacy

Lack of transport

Linkage between local hospital and

IHS

Hospital based AHPs

Housing

Transport provided

Community Health Centre


Welfare

Sport and activities for young people

Referral

Education

Long waiting times

Not culturally appropriate

Ongoing access

Low cost medication

Bulk billing

Insufficient transport*


ICDP staff/program

Employment

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Figure 5: Patient service map site three: Baseline. Source: KPMG.

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Site three (SSE) with ICDP – patient journey map

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Referral

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Access

Referral

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need

Cost of medications

Cooperation with IHS


Barring of patients

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IHPO

Poor attendance

Support Services

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knowledge of full range of ICDP services and benefits

Local PharmaciesLow

awareness

Co-location of some staff at IHS

ATSIOW (C2)

GP Practices

Subsidised medication

(IHS patients)

IHS

IHS diabetes prevention program IHS

Knowledge of IHS programs

Supportive environment

Lack of engagement

Social Stressors

Lack of Patient privacy

Transport provided*

Local Pharmacies

City based hospital

specialists

GP consulting in mainstream and IHS

GP Practices


Hospital based AHPs

Limited engagement with non-service users

Awareness of risk factors



Low cost medication*

City based hospital

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Cultural awareness

Patient privacy

Lack of transport

Linkage between local hospital and

IHS

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Insufficient information to patients about ICDP

ML ATSIOW

(C3)

Welfare

Sport and activities for young people


Referral

Education

Long waiting times

Not culturally appropriate

Ongoing access

Low cost medication

Bulk billing

Insufficient transport

Employment

Figure 6: Patient service map site three: Final. Source: KPMG.144



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3.4 Site four (Outer regional)3.4.1 Site four at baselineThe site is a group of four regional towns, located in a region spanning 51,000 square kilometres. The maximum distance between the towns is 96km. Each of the towns has Aboriginal and Torres Strait Islander residents. There is some movement between the towns themselves and to other regional centres and cities for reasons such and accessing services and visiting family. There were a broad range of facilities available within the region at baseline including four hospitals, a number of general practices including after-hours services, an AHS providing a range of services including outreach, and public and private specialists and AHPs. As in many other places, however, cost of services and access to transport were identified as concerns by community members. Significant gaps in this site were lack of access to any dental service in two of the four towns, and limited access to some specialists and allied health providers across the site.Table 7070 provides summary statistics for site four, covering the local population profile, participation in the PIP Indigenous Health Incentive and conduct of Health Assessments.


Indicators StatisticEstimate Resident Population (2011 Census) 35,402Aboriginal/Torres Strait Islander population (2011 Census) 1,654Proportion of Population identifying as Aboriginal and Torres Strait Islander

4.7%


527


31.9%


49

Site four includes four hubs, three major hospitals, many GPs and pharmacies, an AHS which provides outreach, and one after-hours GPs service. Prior to the implementation of the ICDP no DoGP had an Aboriginal and Torres Strait Islander health program (ICDP or otherwise) and no general practices were found to have Aboriginal and Torres Strait Islander staff.



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System capacity

General practice systemThree of the four towns have hospitals – all of which had emergency, outpatient, obstetrics and elective surgery services, and assessment units at baseline. The largest of the three hospital offered dialysis (limited number of chairs), coronary care, chemotherapy, intensive care, paediatrics, oncology and rehabilitation units. One of the smaller of the hospitals had an Aboriginal Health Education Officer (AHEO) and AHLO at baseline, and the largest hospital had an AHEO – Child and Maternal Health. None of the local hospitals had a community health centre.There were a number of mainstream, private GPs in each of the towns. In one of the towns, a new superclinic had been established. In another town, community nurse were providing health checks for patients during a regular clinic from the community centre. Medications could be purchased from local pharmacies, which were based in each town.Visiting specialists and AHPs were available through the hospitals at regular clinics, and generally they were free of charge. However, not all specialties were available locally (e.g., community members commented that endocrinology, ear, nose and throat, and ophthalmology were not available). Various private specialists and AHPs were also operating in the region. Service providers reported a three to six month wait lists for many specialist services. There were a number of patient and community support services across the region that people could be referred to once diagnosed with a chronic disease. Examples include cancer support services, diabetes support and maintenance groups, and support available through various elder’s groups. Support services were also available through the hospitals (e.g., quit smoking, HMR).At baseline, the DoGP was collecting a range of electronic data, including: demographic information (age, gender); living arrangements; Aboriginal and Torres Strait Islander status/ethnic background; service data (number of clients receiving service and occasions of service); referral data (new referrals); and activity data – consumer/client outcomes and activity by service type. This information was being used to support performance and program management and continuous quality improvement.

Aboriginal and Torres Strait Islander service systemIn one town, there was one AHS which provided comprehensive primary health care at baseline including social and emotional wellbeing, healthy eating and visiting clinics (sexual health, specialist and AHPs). The AHS provided services primarily to people living in the town where it located, although two other communities are also part of the official catchment area.


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The majority of services at the AHS were being bulk billed. In 2009-10 the AHS had a total of 22 staff FTE including two doctors, one specialist /AHP and four AHWs. A total of 16,737 episodes of care were provided in 2009-10 (10,279 to Aboriginal and Torres Strait Islander patients). The vast majority of client contacts (total 17,786) were by doctors (7,200), with AHWs and nurses providing 3,061 and 3,771 respectively. Specialists / AHPs provided only 251 client contacts.At baseline in two of the towns, a well-attended Aboriginal and Torres Strait Islander elder’s group was bringing together elders for healthy activities such as walking and cooking and to hear talks about healthy living from local health and social services/providers. Participants were being provided with education and information about available services in the community, and access to visiting AHPs and regular health checks. At baseline, the AHS was employing a full time practice manager, whose role included coordinating staff and patient bookings. The AHS maintained electronic patient records, which included demographic information and Aboriginal and Torres Strait Islander status.Table 71 below provides a summary of chronic disease related services provided by the AHS in site four AHS in 2009-10.

Table 71: Summary of chronic disease related services provided by the AHS in site four in 2009-10.140

Chronic disease related services provided by the AHS in site four in 2009-10

Yes/No


Yes

Chronic disease management groups YesTobacco use treatment/prevention groups No

AccessGeneral practices were generally considered to be culturally competent by the community members consulted. However, a local service provider reported that many general practices were not collecting Aboriginal and Torres Strait Islander status – limiting their own understanding of their client group. The AHLO and AHEO employed in hospitals were likely to increase the cultural appropriateness

140 Based on information gathered during site visits and research. 147


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of these general practices. No stakeholders knew of cultural awareness training being provided to mainstream primary health care staff at baseline. In one town, there was a new ‘after hours’ GP service in one town. This service operated out of one location between 9am and 6pm, and after 6pm it operated out of the local hospital. This was the only afterhours GP service in the region at baseline. It was reported that many general practices bulk bill.The AHS provided a home visiting service at the discretion of clinical staff, and transport was available to patients who required it – both to tertiary services locally, and in the city (over 500 kilometres away). The AHS also provided support to patients to access community transport if required/preferred. Some outreach primary health care services (vaccinations, maternal child health) were provided.At baseline, the AHS was open from 8am-4.30pm weekdays. Community members reported that sometimes there were long wait times for the AHS (between 1-3 hours). They noted, however, that wait times varied from week to week. The AHS was staffed mostly by local Aboriginal and Torres Strait Islander people, and had a range of strategies to ensure services were being provided in culturally appropriate ways e.g. prioritising Aboriginal and Torres Strait Islander staff in recruitment, local artworks decorating the clinic, and initiatives to increase service access e.g., incentives to get a health check.

Service coordination At baseline, local service providers reported that historically there has been poor engagement (i.e. no networking, cooperation or collaboration) between the DoGP in the region and the AHS. In part, this may have been due to the physical distance between the services, which are located in different towns. With the establishment of the Medicare Local, a formal Memorandum of Understanding will be put in place between these services about working more collaboratively. Independently, the local DoGP (which is forming the Medicare Local) and the AHS were well connected with a number of local services and health care providers at baseline; both mainstream and Aboriginal and Torres Strait Islander. Both informal and formal practices to support collaboration were in place, for example: the DoGP had a relationship with the local Land Council – through which

information was shared, and joint networking opportunities were undertaken, as well as undertaking ongoing collaborating with an Aboriginal and Torres Strait Islander elder’s group; and

the AHS had formal arrangements in place with specialists from mainstream hospitals to deliver monthly Aboriginal and Torres Strait Islander targeted clinics from their premises.

The DoGP reported at baseline that, where there are common clients with other services, coordination was working well, and networking, cooperation and collaboration were working moderately well. The effectiveness of partnerships


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within the local service system was rated 7/10 at baseline across all areas by the Division.141

Patient experienceAt this site, access to health care was impacted by many barriers despite a number of primary, secondary and tertiary health care services being available within the community. These included inconsistencies across the towns in service availability; lack of access to transport; costs associated with health care; and some attitudinal barriers.

PreventionThe key issues identified by community members in relation to prevention were: Many preventive services focussed on older people. Lack of availability of some services to support healthy lifestyles, e.g. fresh

fruit and vegetables, some allied health providers. Attitudinal barriers to accessing health care resulting in. Varied access to health care, and often only ‘as needed’ (not for prevention).There are a number of prevention-focussed activities available to community members, but access to these is varied. Many young people are not engaged with prevention activities (or health activities generally). This may be because many of the prevention activities are focussed on older people, for example, elder’s groups are run in each of the communities, and exercise groups for older Aboriginal and Torres Strait Islander people.

‘For young people there’s rugby, swimming, mucking around, but that’s it really.’142

For younger people, there are sport opportunities but few other health focussed prevention programs. In addition a lot of the prevention activities targeting broader populations, like quit smoking programs, are run from health services, and if people are not engaged with health services they might miss out. There is also an attitude amongst some younger community members that getting a chronic disease is inevitable. Older community members reported that younger people do not care about their health now, and behave in unhealthy ways because the consequences are longer term.

‘Most young people understand what is healthy behaviour, but don’t care or it’s too hard.’143

There is a preference for Aboriginal-focussed programs amongst community members, but community members commented that there are not enough of these available. Regardless of the reasons, a common perception is that many more people could access preventive activities, than currently do.141 Where 10 is very effective service coordination and 0 is ineffective service coordination. Based on information collected during site visits. 142 Community member, site four.143 ibid.


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Community members commented that hearing about the range of preventive services available in each town can be helpful for community members in terms of understanding health problems, and knowing where to go for help. One program, which invites guest speakers to talk to community members about healthy lifestyles, is very popular. There is demand for this kind of activity more frequently from some community members. Many community members who engage with preventive programs have a good understanding of the range of preventive programs and services available, as well as relevant support services. By engaging with these services, they can learn more about healthy lifestyle behaviours.

‘There are patches, tablets, free medicines. You can call Quitline.’144

‘I’m confident in making healthy choices now.’145

‘I understand the impact of weight gain around the middle.’146

There is infrequent traditional food gathering in some towns, but largely people eat food from supermarkets and take away restaurants. In the smallest of the towns, fresh food is expensive, and people have to travel to the other towns to go shopping. Transport issues, however, prevent them from doing this frequently. Family are seen to have a core role in influencing healthy behaviour.

‘It’s hard cos there’s no supermarket here.’147

Diagnosis and treatment The key issues identified by community members in relation to diagnosis and treatment were: Costs associated with health care, and transport to health care, which

impacts on access to health care. Inconsistent access to health services across the towns. Limited access to some types of health care e.g. some medical specialties.In the town with the AHS, the majority of people access primary health care through this service. Most residents in the other towns access general practices including through the new super-clinic. It can be difficult to get an appointment at the AHS due to high demand, and in some cases this is the reason people use local GPs instead. Others have formed a relationship with their local GP and are happy going there. Generally, mainstream primary health care staff are considered culturally competent.Some types of specialists and AHPs are readily available in the region, whereas others visit infrequently or not at all. This tends to be influenced by which specialists are willing to come and provide services rather than need. Patients often have to travel to the large regional centre or capital city to access required 144 ibid.145 ibid.146 ibid.147 ibid.


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specialists and AHPs where there are waiting lists. This means chronic disease can go untreated for some time. However, when people access specialists and AHPs there are clear benefits.In some cases specialist appointments are not kept – either by the patient, or by the specialist themselves.

‘Patients don’t come and then they [specialists] get sick of it.’148

‘They [specialists] don’t stick to their routine.’149

There are a number of barriers that impact on peoples’ access to these services, despite the generally good availability of health care to most community members. One is that it is the norm to engage with health care only as required. This may be because people are scared to find out about a health problem, or they don’t prioritise taking the time to visit the doctor. Other people may be willing to go to one appointment, but do not want to go back for follow up. Where people can get a range of health services all in one go, or all in one place, they are more likely to meet their health care needs.

‘A lot of people only go [to the doctor] when they’re sick.’150

Some of the preventive programs in the region have started to incorporate primary health care service delivery. (e.g., health checks) This is seen as a good way to engage community members who may be reluctant to seek out health care at a clinic.

‘[Local health check program] started because the doctors can’t do it all – the education, the health care, everything.’151

Lack of access to transport is a key barrier to both primary and secondary health care access. The AHS transport is determined based on priority, and is not guaranteed to be available. Community members commented that community and public transport is irregular and can be expensive. There are some services that people always have to travel for such as dental, for which people need to travel up to 190km to a regional centre, or 600km to the capital city, and dialysis, which is not always available locally and can require people to relocate temporarily to avoid constant commuting. The result is that sometimes people cannot attend appointments due to lack of transport, or they rely on family and friends to take them there. Community members commented that there is a lack of understanding of community-supported transport options – how they work and how to access them.

‘One person missed their dialysis cos they didn’t know community transport doesn’t come on the weekend.’152

Cost is another barrier to health care access, and can limit the health care people seek and also the medications they take. Specialist appointments are 148 ibid.149 ibid.150 ibid.151 ibid.152 ibid.


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seen to be the most unaffordable form of health care, because generally primary health care providers bulk bill. Community members commented that some specialists, however, have started to bulk bill Aboriginal and Torres Strait Islander patients.

‘You only pay the gap [for specialist appointments] in the end, but most people don’t have $500 [or the upfront payment] lying around.’153

For people requiring multiple medications, or people on a low income, medications can be expensive. In some cases people prioritise other expenses over medications (i.e. do not take medications) or share their medications with family and friends.

‘I used to have more than five prescriptions. I had to decide which ones to buy first. Which ones I needed most.’154

Confidentiality is another key barrier, with a number of community members saying they do not like to go to health services where people they know, work.The table below shows professional attendances and pathology services in 2009/20 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011. Table 72 shows professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.






3,901 2,413 527 7.4 4.6

Ongoing treatment and supportThe key issues identified by community members in relation to ongoing treatment and support were costs and transport issues. GPs are seen as an important source of support for people who are diagnosed with a chronic disease. Because the towns in the region are small, GPs tend to know their patients and there are good relationships between many patients and their GPs.In some of the towns there are also chronic disease specific support services available, for example a diabetes support group that meets three times a year and provides podiatry, dietetics and vision checks, and a cancer support program 153 ibid.154 ibid.


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run by CAN assist. However, the availability of these groups is variable across the towns, and there is a perception that people have to know about the groups to access them.

‘GPs at the AMS can help people who have a chronic disease to look after themselves.’155

The issues experienced relating to transport mean there are challenges with accessing ongoing secondary and tertiary care for some people.

Baseline assessment The table below draws together the information presented above about site four at the final stage. Against conceptual framework domain characteristics, this table provides the rating156 the evaluators gave the site at baseline. Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.

155 ibid.156 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory.


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Table 73: Assessment against the conceptual framework.Domains Characteristics Rating AssessmentSystem capacity


2 No deficiencies in terms of infrastructure were reported; however, there were some gaps in service delivery noted (see below).


1 In some towns, there were adequate health workers and services whereas, in others, it was more limited. The AHS workforce was large and included many local people.


1 Gaps in service delivery highlighted included specialist and allied health services and transport. In some cases, according to patients, their health needs were compromised by the high demand and limited availability of these services.


1 AHS practice management appeared sound. Inadequate information was available about monitoring and evaluation. Inadequate information about clinical information systems was utilised.


1 There appeared to be commitment from the AHS to Aboriginal and Torres Strait Islander health. General practices had variable uptake of the PIP Indigenous Health Incentive, and mixed attitudes about Aboriginal and Torres Strait Islander patients were reported. There was no information about the DoGP.


1 In some locations within the site, services were accessible but, in others, they were not. Transport was limited, and many people did not have private transport. Outreach between towns was limited.

Services are financially accessible to patients. 1 Several supports to provide financially accessible health

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Domains Characteristics Rating Assessmentcare are available in this site including bulkbilling GPs and visiting specialists and AHPs available through the hospitals at free clinics. However, the cost of health care (particularly specialist services and medications) and the cost of transport to access services, was still identified as a major barrier by many community members.


2 Services were targeted to a variety of groups and included specific Aboriginal and Torres Strait Islander services, and general practices catering to Aboriginal and Torres Strait Islander patients.


1 The AHS included families in the treatment of health problems. There was inadequate information about mainstream primary health care.


1 This was reported to be variable, with some general practices and the AHS having made significant effort in this area, and other (mainstream) services having made no effort in this area.


1 This was variable according to service providers and patients, particularly amongst general practices (some of which were reported to not have been receptive to change) which did not think they had Aboriginal and Torres Strait Islander patients, and were not signed up for the PIP Indigenous Health Incentive.


2 The AHS employed local Aboriginal and Torres Strait Islander staff, and staff were known to community members. Strategies were put in place within the AHS to support culturally appropriate care. AHLOs are also in place.

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Domains Characteristics Rating AssessmentCultural awareness training and immersion is available to the health workforce.

0 None reported.



1 There was ineffective networking, coordination and collaboration between the DoGP and AHS, however good relationships between individual services were present.


1 This was limited by the poor relationships within some parts of the sector. As reported by patients, experiences in this area were highly variable (e.g., in some cases, patients have to re-tell their story multiple times but, in others, they do not).


2 Between the DoGP and Local Aboriginal Land Council (LALC), local elders’ groups.


2 Between the AHS and the secondary and tertiary services.


2 There did not appear to be duplication, rather, there were gaps in the service system, particularly for people living in smaller towns.

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Changes expected to occur as a result of ICDP at baseline One AHS and one DoGP were due to receive funding for the ICDP at this site at baseline. The DoGP covered three of the four towns, whereas the AHS covered only one town. Thus, the likely impact of the ICDP across the region was variable. The following changes as a result of the ICDP were expected at baseline: Funding for a RTSHLT had not been allocated within the site at baseline,

however the recently appointed ATSIOW planned to engage the community in changing their lifestyle behaviours (e.g., diet, exercise, accessing health checks) through organised groups such as elders groups. Thus, the ICDP was expected to add an additional healthy lifestyle service.

The AHS and some general practices were planning to sign on to the PIP Indigenous Health Incentive at baseline. Access to PIP Indigenous Health Incentive care plans and to the PBS co-payment measure was expected to result in affordable access to medications across the region.

The perceived cultural appropriateness of general practices was variable but practices were generally not perceived to be culturally competent. Thus, the IHPO was expected to have an important role in increasing the cultural competency of general practices for the purpose of increasing access to these services by Aboriginal and Torres Strait Islander people. The supplementary services funding and the transport expected provided by the ATSIOW were considered likely to address a significant transport gap, particularly where transport between towns or to major centres is required.

3.4.2 Site four at final The key characteristics of the site remained consistent between baseline and final stages in terms of population characteristics and the service system. The DoGP had transitioned to a Medicare Local by the final stage.

ICDP workforce investment and activity at site fourAt site four, a total of 11.75 FTE ICDP workers were allocated across the Medicare Local and the AHS by final stage, as Table 74 below shows.


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Table 74: ICDP workforce allocation (FTE) within site four, 2012-13 (various dates).157

Position AHS

Medicare Local

Total Allocation

IHPO 0 1.75 1.75ATSIOW 1 2.00 3.00RTC 1 0.00 1.00TAW 3 0.00 3.00HLW 2 0.00 2.00ICDP practice manager

1 0.00 1.00

Total 8 3.75 11.75

ICDP workforce investment in the AHSRTSHLT: The RTSHLT had six team members at final stage; one RTC, two HLWs and three TAWs. Team members had been in place for between one month and one year. The team is focused on both smoking and healthy lifestyles. The majority of activities provided by the team incorporate tobacco and healthy lifestyle messages and supports, and generally TAWs and HLWs together, run the activities. The team has focused on group programs such as fitness and cooking classes. Within these, smaller smoking components have been incorporated, for example the team has offered people who sign up for fitness classes the opportunity to try some NRT (with the approval of the GP) if they want to quit smoking. Although the team is hosted by the AHS, they are seen as part of the organisation and one of a number of health prevention services available. Other services that the team has linked with are: internal services including GPs who can provide smoking cessation support,

AHPs, a mums and bubs program and a drug and alcohol program; and external services, such as Quitline and the local council. An existing fitness program has been incorporated into the RTSHLT. Practice manager: The ICDP practice manager was working in the AHS for 10 years prior to starting in her current role; previously she was the practice administrator. The ICDP funding allowed the AHS to expand the role, and the practice manager now manages the clinical team within the AHS and is responsible for staff professional development, in addition to her existing practice administration duties. The final stage consultations suggested the 157 Workforce data provided by the former Department of Health and Ageing. Note there are different datasets for each worker type, and each provide point in time snapshots at dates within 2012-13.


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practice manager did not have a lot of involvement with the PIP Indigenous Health Incentive and PBS Co-payment measures, as registrations and other paperwork for these initiatives were the responsibility of the Manager, Primary Health Care. Since she started two years ago, the practice manager has focused on improving the operations of the AHS by: expanding their programs and services e.g., she sought funding for additional

AHPs to run clinics from the AHS; improving practice systems including updating the AHS’s recall and reminder

system for patients; and ensuring staff have access to the professional development they require. ATSIOW: The ATSIOW had been employed for three months when the final stage consultations were conducted, and came from a non-health related background. When he started in his role, he was told that his focus should be on increasing Aboriginal and Torres Strait Islander peoples’ engagement with the AHS. The ATSIOW was operating across the whole region at final stage. This included providing outreach to a number of towns between one and three hours drive away. The key mechanisms through which he was working to increase engagement at final stage were: promoting AHS services within the main town (where the AHS is located) and

in other locations in the region; encouraging people to attend programs or see a GP at the AHS; and organising transport for people located outside of the main town, such as

transport buses.

ICDP workforce investment in the Medicare LocalIHPO: The IHPO has been employed since early 2010. When she started, she developed a needs assessment for the region. Based on this needs assessment, her initial focus was on running programs for population sub-groups aiming to increase their access to health services. When the ATSIOW came on board, she shifted her focus to: promoting the ICDP to general practice practices in the region; encouraging GPs to register for the PIP Indigenous Health Incentive and PBS

Co-payment; and running cultural awareness training and information sessions on Aboriginal

and Torres Strait Islander health with local providers.Throughout this shift in focus, she has tried to ensure she is known and seen in the community through attending events. She has become a ‘go to person’ within her home town, where she spends most of her time. The Medicare Local that she works in is located in a different town. ATSIOW: The ATSIOW started around nine months after the IHPO, and since this time has focused on supporting community members to access health care


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through providing them with information, encouragement and transport, booking their appointments and attending appointments with them. Along with the IHPO, she has attended events and visited GP practices to promote the ICDP. CCSS: The Care Coordinator was the last of the ICDP workers to be employed in the Medicare Local, in mid-2011. The model of CCSS in this region is fairly typical and consistent with the guidelines. The Care Coordinator receives referrals from GPs and other sources (self-referrals, ATSIOWs). Provided patients meet the criteria, she starts to work with them to identify and implement services to meet their needs. The Care Coordinator frequently accesses SS funds to cover transport and specialist and allied health appointments. The Care Coordinator has also been trained in the Flinders CDSM program, thus some of her focus is on providing self-management support. The Care Coordinator does not have a clinical background, although she has completed some study in health in the past. Prior to the transition to Medicare Local, a nurse worked closely with the Care Coordinator to provide clinical support as required. Since the transition, this person’s role has changed and the Care Coordinator no longer has this support, which she sees as a risk. At final stage, all of the ICDP workers in the Medicare Local in this site were local, Aboriginal people who are known to the community. This was seen (by the workers themselves and their managers) to be of benefit in engaging a broad range of Aboriginal and Torres Strait Islander people with their services. MSOAP-ICD: MSOAP-ICD commenced in 2011 in site four. The program is run by the Medicare Local (originally this was the DoGP) and as at early 2013, MSOAP-ICD services were being provided across five different towns in the region. No clinics were being run in the main town where the AHS operates, this was because the AHS was already providing free specialist and allied health services when the funding became available. Generally, the clinics were being held once a month, although the service delivery locations and specialties varied from site to site. More allied health than specialist services were being provided, and these focused on Diabetes (e.g., Diabetic education, Dietetics, Podiatry, Endocrinology). Each of the locations has different referral pathways into MSOAP-ICD; in some of the sites, the ATSIOW has a role in linking patients in with the clinics, whereas in others, the majority of referrals come from GPs. The level of attendance at each of the clinics varied at final stage, as did the number of ‘no shows’.

Impact of the ICDPEach of the changes expected to occur as result of ICDP investment were found to have occurred at the final stage. These expected changes were: Increasing the cultural competency of general practices Increasing access to general practices Additional healthy lifestyle service Address transport barriers


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Reduced financial barriers to medicines Improved access to medicinesIn addition to these expected changes identified at baseline, several other impacts were also observed. Overall, the key changes as a result of ICDP investment at this site, with reference to the conceptual framework, were: system capacity: an expanded health workforce including Aboriginal and

Torres Strait Islander workers within the mainstream sector for the first time, and new prevention, primary and secondary services and programs; tailored to community needs;

access: improved physical accessibility (albeit more so in some parts of the region than others) and cultural appropriateness of general practices, leading to increased engagement with these services; and

service coordination: initial improvements, followed by a reduction in engagement and information sharing between the sectors.


Changes to system capacityThrough the ICDP, the number of Aboriginal and Torres Strait Islander workers in place in the region increased. Within the Medicare Local at final stage there was a team of Aboriginal and Torres Strait Islander workers who were the first Aboriginal workers in the DoGP (now Medicare Local) when they started in their ICDP roles. The RTSHLT within the AHS also represents six additional workers, however an AHS organisational representatives noted that the number and type of workers within the AHS is always fluctuating as funding becomes available and ceases. What this team has brought to the AHS is a new type of service that was not previously available, as discussed below. Analysis of OSR data shows that while the range of types of services remained consistent between baseline and final stages (see Table 76 below). There was an increase in FTE overall, and in the total number of clients at this site.


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Table 75: Summary of chronic disease related services provided by the Indigenous organisation in site four for 2009-10 and 2011-12.158


Yes Yes

Chronic disease management groups Yes YesTobacco use treatment and/or prevention groups Yes YesNote: there are a number of limitations with this data, which are explored in the appendices.

Table 76: Summary of Indigenous health organisation service provision in site four for 2009-10 and 2011-12.159


2.00 2.00 0.00%


1.14 0.90 -21.05%


61.41% 49.98% -18.61%

Total number of clients 6,077 7,139 17.48%Aboriginal or Torres Strait Islander clients as a proportion of total clients

17.35% 24.51% 41.27%

Note: there are a number of limitations with this data, which are explored in the appendices.

158 Based on OSR data, provided by the former Department of Health and Ageing. 159 ibid.


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Table 77 Site population PIP Indigenous Health Incentive statistics.Statistic FigureAboriginal and/or Torres Strait Islander population160 1,654Estimated number Aboriginal and/or Torres Strait Islander population with a chronic disease161

422


100%

Across the region, the ICDP led to an expansion in the number and types of programs and services available to Aboriginal and Torres Strait Islander people. In some towns, the ICDP has resulted in Aboriginal and Torres Strait Islander-targeted programs and services being available for the first time.The RTSHLT is the first dedicated tackling smoking and healthy lifestyle support service for Aboriginal and Torres Strait Islander people in the region. While the AHS previously provided smoking cessation support (through drug and alcohol counsellors and GPs) this was clinical, one-on-one support, which is distinct from the group based and community level programs and activities the RTSHLT provides.In the past, some care coordination services were available in the region, but these were mainstream targeted and were been well utilised by Aboriginal and Torres Strait Islander people. CCSS thus represents a new Aboriginal and Torres Strait Islander-specific service. While a number of Aboriginal and Torres Strait Islander-specific support groups were operating across the region in the past, these were not focused on health care and largely targeted elders. The dedicated supports for health care access, being provided by the ATSIOW, build on the supports previously available by focusing on health and targeting the broader Aboriginal and Torres Strait Islander population. The AHS has been the only source of free specialist and allied health services for Aboriginal and Torres Strait Islander people in the past, and these services were not provided beyond the main town where the AHS is located. Private specialists and allied health services are now provided through SS funds and MSOAP-ICD across the region. This represents completely new services for Aboriginal and Torres Strait Islander people in three of the four towns.

160 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra.161 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.162 MBS data supplied by the former Department of Health and Ageing, 2013.163 This is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period. As such the Patients (EverIHI) values may not always match the numbers in the proceeding tables.


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Although in the past, many of the local GPs were providing services to Aboriginal and Torres Strait Islander people, the Medicare Local reported that many were not providing the desired level of care (e.g., identifying Aboriginal and Torres Strait Islander patients, spending adequate time with patients, bulk billing patients). Two GP practices in the region implemented specific Aboriginal and Torres Strait Islander clinics between baseline and final stages, with the encouragement of the IHPO, which represented an increased level of service. The role of the ICDP practice manager has focused on recruiting more workers and providing additional services from the AHS. This has the potential to enhance the capacity of the organisation, and should continue to do so over time.

Changes to accessibilityThe ICDP has also increased the cultural appropriateness of general practices within this site, which were not considered culturally appropriate previously. The IHPO reports that most services are now registered for the PIP Indigenous Health Incentive. The IHPO worked closely with these services to change their approach to dealing with Aboriginal and Torres Strait Islander clients, as noted above. Perhaps more effectively in this region, the ICDP placed local Aboriginal and Torres Strait Islander workers being placed in general practices (e.g., the Medicare Local), which led to community members feeling more comfortable engaging with this service and the supports provided by this service (including the Aboriginal and Torres Strait Islander clinics within two local GPs, noted above, and the MSOAP-ICD program). This has led to improved access. The ICDP workers (ATSIOW and IHPO) further facilitated access by engaging closely with existing Aboriginal and Torres Strait Islander support services. Through attending these elders programs, these workers have built relationships with patients the flexibility within the C3 measure has allowed the ATSIOW and IHPO to spend their time in this way. The number of PIP Indigenous Health Incentive registered patients is illustrated in the table below. Based on chronic disease estimates the EverIHI group (as at 2011) is larger than the estimated number of Aboriginal and Torres Strait Islander people with a chronic disease in this site. This is likely to have (at least in part) resulted from the ICDP workers’ focus on promoting this measure to local practices. There was growth in the number of Health Assessments provided to EverIHI patients after the baseline year of 2009-10 at site four, driven by an increase in the number of providers providing Health Assessments (Table 78). There was no meaningful change in the number of Health Assessments per provider between 2010 and 2012. There was also a substantial increase in the number of Health Assessments per 100 EverIHI patients (Table 79). Of the three regional sites, site four had the highest number of Health Assessments per 100 EverIHI patients. There was also growth in the numbers of allied health follow-up services after June 2010, in line with the observed growth in the numbers of Health


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Assessments (Table 80). Between 2009-10 and 2012 the allied health follow ups had increased from 16 to 57 per 100 EverIHI patients (Table 81).There was some growth in attendances at specialists from mid-2011, linked to an increased number of specialist providers (Table 82). The change in specialist attendances per 100 EverIHI patients was also fairly limited. In the baseline period it was 52 specialist attendances per 100 EverIHI patients and in 2012 it was 57 specialist attendances per 100 EverIHI patients (Table 83).Numbers of GP attendances were decreasing prior to the baseline year but increased steadily after then (Table 84). That growth was fuelled by an increased number of GPs serving the Aboriginal and Torres Strait Islander community at site four. This resulted in GP attendances increasing from 762 per 100 EverIHI patients in the baseline period to 944 per 100 EverIHI patients in 2012 (Table 85).

Table 78: Numbers of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments and average Health Assessments per provider164, site four, by six month period, 2007 to 2012.165

Six months ending





Table 79: Number of EverIHI patients, Health Assessments and Health

164 Up to June 2010, this is the minimum number of individual providers of Aboriginal and Torres Strait Islander Health Assessments. The actual number may be higher as multiple MBS items were used for these assessments. After June 2010, this is the actual number of providers of MBS item 715.165 MBS data supplied by the former Department of Health and Ageing, 2013.


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Assessments per 100 EverIHI at site four in 2009-10 (baseline period) and calendar year 2012.166

Statistic 2009-10

2012


12 40

There was also an increase in pathology tests for EverIHI patients at site four from mid-2011 (Table 8686). This increase extended into the number of pathology tests per EverIHI patient. In the baseline period there were 596 pathology tests per 100 EverIHI patients and in 2012 there were 644 pathology tests per 100 EverIHI patients.These findings suggest some changes to the primary care stage of the patient journey for EverIHI patients at site four. There was increased monitoring (through health assessments) for Aboriginal and Torres Strait Islander patients with or at risk of a chronic disease. This appeared to have led to increased pathology testing and also increased use of allied health follow up services. This last increase appears to have been appropriately targeted, as the increase in use of follow up services was proportional to that for health assessments. There also was increased access to specialist care for EverIHI patients.

166 ibid.166


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Table 80: Numbers of allied health follow up services167 for EverIHI patients at site four, by six month period, 2007 to 2012.168

Six months ending



Table 81: Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site four in 2009-10 (baseline period) and calendar year 2012.169

Statistic 2009-10

2012


29 28

167 MBS subgroup M03—Allied Health Services plus MBS subgroup M11--Allied Health Services For Indigenous Australians Who Have Had A Health Check.168 MBS data supplied by the former Department of Health and Ageing, 2013.169 ibid.


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Table 82: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site four, by six month period, 2007 to 2012.170

Six months ending



Table 83: Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site four in 2009-10 (baseline period) and calendar year 2012.171

Statistic 2009-10

2012


52 57

170 ibid.171 ibid.


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Table 84: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site four, by six month period, 2007 to 2012.172

Six months ending



Table 85: Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.173

Statistic 2009-10

2012



762 977

172 ibid.173 ibid.


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Table 86: Numbers of pathology services for EverIHI patients at site four, by six month period, 2007 to 2012.174

Six months ending

Pathology services


Table 87: Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI at site four in 2009-10 (baseline period) and calendar year 2012.175

Statistic 2009-10

2012



596 644

Finally and again, as at all non-remote sites, the availability of CtG scripts increased access to medicines, according to patients. This is supported by the data, which shows sustained high growth in the number of PBS scripts dispensed to EverCtG patients between 2007 and 2012. From July 2010 to December 2012, that growth was double that for the period from January 2007 to June 2010. See Table 88 below.

174 ibid.175 ibid.


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Table 88: Number of PBS scripts dispensed to EverCtG patients by six month period, site four, 2007 to 2012.176

Six months ending

Scripts

June 2007 7,326December 2007 8,608June 2008 8,196December 2008 9,815June 2009 8,934December 2009 10,25

5June 2010 9,931December 2010 12,17

0June 2011 13,09

5December 2011 15,46

3June 2012 14,75

4December 2012 16,97

0

For drugs used in diabetes (ATC class A10) the escalation in growth rates described in section 5.2 of this document was most marked for site four (9.5 times higher average annual growth after June 2010 than before). The qualitative data does not provide an explanation for this trend. Perhaps facilitating this increased uptake of services, a significant impact for patients resulting from the ICDP was an increase in the physical accessibility of services, through provision of transport support. This is explored below.



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Changes to service coordinationPrior to the transition to Medicare Locals, the implementation of the ICDP led to increased engagement between the then DoGP and Aboriginal and Torres Strait Islander services. The local ICDP workers recruited by the DoGP knew some of the AHS workers, and were able to improve what were poor relationships (largely due to geographical distance between these services) from the ground-up. Just prior to the transition, ICDP workers reported that senior managers in both services were meeting and engaging for the first time. The ICDP workers in the DoGP were engaging regularly with local Aboriginal and Torres Strait Islander services involved in delivering the elders programs mentioned previously.The transition to Medicare Locals impeded this as follows: the management staff within the DoGP changed and this meant relationships

with the AHS management staff had to be started from scratch; and restrictions were placed on the ICDP workers in the amount of time they could

spend on outreach, limiting their regular engagement with other local Aboriginal and Torres Strait Islander services including those in the AHS.

ICDP workers in the Medicare Local, and AHS representatives, agreed that this negatively impacted on service coordination within the region. However, both also reported good relationships between individuals in service delivery roles across the regional service system. The transition to Medicare Locals resulted in the majority of ‘other changes’ at this site. The reduced level of service coordination discussed above was a negative change. It is likely that this will improve over time, as relationships between management staff improve. A positive outcome of the transition was an increased focus on data collection and reporting within the Medicare Local compared to what was occurring within the DoGP.

Impact of the ICDP on patient experience The most significant improvements to the patient journey at this site can be linked back to improved physical accessibility to required services as a result of transport support. The following changes to the patient journey were noted: Increasing community members’ motivation to make healthy lifestyle

changes. Community members commented that the RTSHLT programs have addressed a number of barriers to engaging in healthy lifestyle changes: - a lack of Aboriginal and Torres Strait Islander specific healthy lifestyle

programs being available was one barrier which has been addressed by the RTSHLT running Aboriginal and Torres Strait Islander-targeted gym programs and cooking classes;

- through running group activities, the RTSHLT has been able to show people that if others can do it, so can they;


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- community members reported that because the RTSHLT is based in the AHS, where they would normally go to access health care, it is easy to access support and advice from this team.

‘People around here have had bad experiences with DoCS workers threatening to take their kids away, so they sometimes avoid health workers. But now that the workers are involved with the AMS more and more people are willing to try their healthy living programs. Lots of Aboriginal people go to the gym now or go to the elders program to get healthy. Word is spreading about these things.’177

Improved geographical accessibility. In this region, Aboriginal and Torres Strait Islander community members had variable access to different services depending on where they were located. While each town has some health services, many of the major services including the AHS, Medicare Local and hospitals are located in two of the towns; thus community members residing in other towns often had to travel to access services they required and many did not have access to private transport. The ICDP has improved accessibility in the following way:- ATSIOWs (in both the AHS and Medicare Local) provide transport to people

to access services within their own town or those located in other towns in the region – this includes the ATSIOW driving patients to services, or organising transport for them.

- The SS funds are used to finance transport that is organised for patients locally. The SS funds are also used to pay for transport and accommodation when patients have to travel to major cities for health care.

- The RTSHLT, ATSIOWs and Care Coordinator all provide outreach services across the region.

Reduced financial barriers. The cost of medicines, local specialist and allied health appointments and transport and accommodation costs associated with travelling to access required services, were identified as barriers here. These have been somewhat addressed through the CtG scripts, CCSS and MSOAP-ICD measures.

Improved community members’ understanding and confidence to access services. The ATSIOWs (in both the AHS and Medicare Local) and Care Coordinator delivered messages to community members they have engaged with, such as finding out about a health problem earlier is better than finding out later.

177 True to life vignette. These vignettes present de-identified examples that are very similar to situations observed during the evaluation activities.


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‘We have many doctors in the community. Some doctors are hard to get into and others are easy. The problem is that the easy doctors have rude reception staff so people don’t go to them unless they are really sick. [Care coordinator] told us about a person who had diabetes and didn’t go to the doctor until it was too late and they lost their feet. Now more people go to the doctor early.’178

Ongoing challenges related to ICDPThree key interrelated barriers were evident at site four at final stage. These included: Limited knowledge of the RTSHLT amongst Aboriginal and Torres Strait

Islander community members consulted. Although this team had been in place for almost a year at the time of final consultations, they were not well known outside of the main town.

Size of the region. ICDP workers in outreach roles (e.g., the ATSIOW and the RTSHLT, which is expected to cover the entire region) identified the significant size of the region and the geographical spread of the Aboriginal and Torres Strait Islander population as a key challenge. This limited their ability to reach the broader population.

Community expectations for outreach not being met. Some of the community members consulted had heard about services that they did not see being provided in their community. This led to a perception that the workers were not doing their job, or were favouring specific towns over others.

3.4.3 Final assessmentTable 89, Table 90, Table 91 below draw together the information presented above about site four at the final stage. Against the conceptual framework domains characteristic, this table provides: the rating the evaluators gave the site at baseline179; the rating the evaluators gave the site at final stage180; the key changes observed; and what these changes appear to be attributable to.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.Figure 7 and Figure 8 below provide a visual representation of the findings within this chapter as at baseline and as at the time of the final evaluation. Each figure

178 ibid. 179 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory. 180 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory/moderate change from a low base. 3= notable change from baseline.


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is presented as a systems map which details, on a single page, the health services provided within the community, primary, secondary and tertiary sectors within the site. Each patient services map includes the: AHS and mainstream services/supports located within the site; ICDP staff and programs (post-ICDP map only); linkages between services, where these are in place; and identified facilitators and barriers to patient accessibility to these services.


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2 3 There were no deficiencies in infrastructure at baseline. By early 2013, both the Medicare Local and AHS had moved to larger premises. The AHS purchased cars for the RTSHLTs.

Different sources of funding were used for these changes including non-ICDP core department funding (larger offices) and the ICDP (RTSHLT vehicles).


1 3 At baseline, there were adequate workers in some towns and not others. The ICDP workers now do a lot of outreach, and the four key towns are generally covered. New non-ICDP workers are also in place.

The ICDP has created 11.75 FTE additional positions in the region including 3.75 FTE in the mainstream sector. Some of the staff recruited to the AHS have been funded through ICDP and some through other programs. The other sources of funding for workers include Healthy 4 Life and other COAG funding.


1 3 At baseline, there were a number of gaps in service delivery including specialist and allied health services and transport. In some cases, according to patients, their health needs were compromised by the high demand and limited availability of these services. There is now a broader range of programs available in both the AHS and mainstream sectors including ATSIOWs to provide transport and MSOAP-ICD for specialist service provision. The AHS noted that programs such as CtG scripts and the PIP Indigenous Health Incentive allow a greater focus on Aboriginal and Torres Strait Islander patient needs.

Many new programs are ICDP funded. All of those in the Medicare Local are, but the AHS has other sources of funding in addition to the ICDP.

Services have practice 1 2 There did not appear to be any significant changes in The transition to Medicare Locals appears to 176



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management and clinical information systems with a focus on good practice patient care and quality improvement.

this area. While the AHS had a new ICDP practice manager, this position involves an expansion of an existing role not a new role. No issues with clinical information or practice systems were raised. Monitoring and reporting is an increased area of focus for the Medicare Local, but this does not appear to be being done consistently.

have facilitated most of this change.


1 2 The AHS was always and remains committed to Aboriginal and Torres Strait Islander health. There has been an enhanced focus on Aboriginal and Torres Strait Islander health within a number of general practices such as GP practices. ICDP workers in the Medicare Local report the new leadership structure does not value or understand Aboriginal and Torres Strait Islander health as much as the DoGP leadership did.

ICDP workers have contributed to increased understanding of Aboriginal and Torres Strait Islander health amongst general practices and other services by providing print materials and conducting training and information sessions with practices.


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1 3 At baseline, there was variable access to services across sites. With the ICDP investment across the sites (either staff stationed in towns, or providing outreach to towns), the accessibility of services is now increased. Transport support available from

ICDP programs have led to most of the increase in outreach and transport availability.

177



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the ATSIOWs and funded through SS funds facilitates access when the required services are located far away.


1 2 The cost of medicines, local specialist and allied health appointments and transport and accommodation costs associated with travelling to access required services, were all identified as barriers which have been somewhat addressed through the CtG scripts, CCSS, MSOAP-ICD and ATSIOW measures.

ICDP programs have reduced financial barriers (CtG scripts, CCSS, MSOAP-ICD, ATSIOWs).


2 2 At baseline, services were targeted to a variety of groups and included specific Aboriginal and Torres Strait Islander services, and general practices catering to Aboriginal and Torres Strait Islander patients. This was unchanged at early 2013. ICDP programs are providing Aboriginal and Torres Strait Islander specific health promotion services that were not available in the past.

The RTSHLT funding is enabling provision of Aboriginal and Torres Strait Islander specific health promotion.


1 3 The AHS reported that they include families in the treatment of health problems at baseline and final stages. Patient reports suggest that some practices have become more culturally aware and that other health care services such as the hospital and pharmacies are ‘getting used to’ dealing with Aboriginal and Torres Strait Islander patients; increasing their cultural understanding.

The PIP Indigenous Health Incentive has provided impetus for change. The IHPO and ATSIOW have worked with GP practices to support practice change and advocate for Aboriginal and Torres Strait Islander health.

178



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1 1 This was reportedly variable at both baseline and final stage, with some general practices and the AHS making significant effort in this area, and other (mainstream) services making no effort in this area.

The PIP Indigenous Health Incentive may have provided impetus for change in some areas, but this appears to be driven by individuals with interest in Aboriginal and Torres Strait Islander health.


1 1 There were high levels of receptivity within the DoGP initially, but the new Medicare Local does not seem as supportive. Pharmacists have been very receptive overall, whereas within GP practices this has varied. The AHS has become more open to change the way things are done, such as increasing claiming of Medicare items.

Differences in organisational culture between the old DoGP and new Medicare Local appear to account for the backward shift in this area. The PIP Indigenous Health Incentive may have provided impetus for change in some areas, but this appears to be driven by individuals with interest in Aboriginal and Torres Strait Islander health.


2 3 All of the ICDP workers recruited in the AHS and Medicare Local are local Aboriginal and Torres Strait Islander people, some of whom have been working in the region for many years. Some of the MSOAP-ICD providers are also locals with ties to the target group from previous allied health and specialist programs delivered through organisations like the land council.

The ICDP has created positions in this region that are most appropriately filled by local Aboriginal and Torres Strait Islander people, such as ATSIOW and RTSHLT positions.


0 3 Training is available through PIP Indigenous Health Incentive through the online Royal Australian College of General Practitioners (RACGP) training. The IHPO and ATSIOW have also provided face-to-face training to a number of local practices.

Both of these types of training are linked to the ICDP B3a and C3 measures.

179



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1 1 The historically ineffective networking and information sharing between the DoGP and AHS improved significantly with the implementation of the ICDP. However, some damage was done in the transition to Medicare Local. Workers report they are now unable to do the required level of ‘out of office’ work to maintain relationships with the AHS, which is in another town.

The ICDP placed local Aboriginal and Torres Strait Islander people in the DoGP who had existing relationships with AHS service providers. These relationships facilitated better networking. The transition to Medicare Locals appears to have compromised this.


1 1 There is a patient focus between some individuals and programs, and not others; coordination can thus be compromised by staff turnover.

As above.


2 2 The workers in the region appear to have good relationships and communicate well when they are known to each other. Some of the new information sharing systems have also facilitated this.

As above.

Formal mechanisms or practices that support service coordination and patient centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds.

2 2 Both the Medicare Local and AHS are involved in the PCEHR initiative, which allows for easier formal information sharing.

The PCEHR is a part of broader health reform and is not part of the ICDP.

Services within the system are 2 2 There does not appear to be duplication due to the In this region different ICDP programs

180



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complementary and there is no duplication.

geographical spread of the towns and the range of different services available in each town. This has not changed since baseline.

have been funded in different locations.

181



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Site four (SSE) pre ICDP – patient journey map

Com

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Terti

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ICDP linkage

Non-ICDP linkage



Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

Ongoing access

Scripts

Ongoing access

Ongoing access

Referral

Referral

Referral

Referral

Ongoing access

Ongoing access

Ongoing access

Ongoing access

Scripts

Transport provided

Support Services



IHS

GP Practices

Time away from

community

Local Pharmacies

PHC visiting specialists

IHS

Bulk billing



City based hospital

specialists

Housing

Welfare


Cost of transport*

Education

Community based AHPs

Long waiting times for and at appointments

GP Practices


Transport provided by IHS

Lack of community engagement in

follow up appointments*

Lack of community awareness of full

range of local services available*


Cost of transport

Lack of practitioner

awareness of full range of local

services available*

Sport and activities

Long waiting times for and at

appointments

Active coordination with other programs

City based hospital

specialists

Lack of continuity of care*

Links with IHS programs

Local Pharmacies

Bulk billing

Low cost medication

(incl. QUMAX)

Lack of transport*

Employment

Barrier expected to be reduced by

ICDP staff/program*

Figure 7: Patient service map site four: Baseline. Source: KPMG.

182



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Site four (SSE) with ICDP – patient journey map

Com

mun

ityPr

imar

ySe

cond

ary

Terti

ery



ICDP linkage

Non-ICDP linkage



ICDP staff/program

Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

*ICDP facilitator


Ongoing access

Scripts

Ongoing access

Ongoing access

Referral

Referral

Care Coordination

Coordinate

Referral

Referral

Referral

Ongoing access

Ongoing access

Ongoing access

Referral

Ongoing access

ICDP support

Care Coordination

Scripts

Transport provided

Support Services



ATSIOW (C2)

Care Coordinator

IHS

GP Practices

Time away from

community

Local Pharmacies


RTSHL

IHS

Bulk billing

Links with RTSHLT*

Cost of medications


City based hospital

specialists

Housing

Welfare


Cost of transport

Education

Community based AHPs

ATSIOW (C3)

Community awareness and

understanding of CtG Scripts*

Long waiting times for and at appointments

GP Practices


Transport provided by IHS

Lack of community engagement in

follow up appointments

Lack of community


services available



Cost of transport

Lack of practitioner


services available

Sport and activities

Lack of follow-up appointments

Increased transport options* Long waiting times

for and at appointments

Active coordination with other programs

City based hospital

specialists

Lack of wider community

understanding of ICDP registration

and benefits

IHPO

Lack of continuity of care

Links with IHS programs

CtG scripts complementing

existing pharmaceutical

programs*

Local Pharmacies

ICDP support


Bulk billing

Low cost medication

(incl. QUMAX)

Lack of transport

Employment

Figure 8: Patient service map site four: Final. Source: KPMG.

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June 2014

3.5 Site five (outer regional)3.5.1 Site five at baseline This site is an outer regional site located around 100 kilometres from a large city. The Aboriginal and Torres Strait Islander community is dispersed amongst the several small and medium size towns in the site.At baseline most of the site was considered to be experiencing general practice shortage. Services to Aboriginal and Torres Strait Islander people in the area are primarily provided by a variety of general practices. Key concerns raised by community members included waiting times for primary health care and secondary services, and the lack of cultural appropriateness of providers. This site also had the lowest proportion of patients registered for PIP Indigenous Health Incentive of all sites, and community knowledge of CtG scripts was also particularly low (based on the two focus groups undertaken). Table 78 provides summary statistics for site five, covering the local population profile, participation in the PIP Indigenous Health Incentive and conduct of Health Assessments.


Indicators StatisticsEstimate Resident Population (2011 Census) 65,298Aboriginal/Torres Strait Islander population (2011 Census) 3,653Proportion of Population identifying as Aboriginal and Torres Strait Islander

5.6%


76


2.1%

Number of Aboriginal and Torres Strait Islander Health Assessments by site in 2009-10

NP

Site five includes three hubs, two major hospitals, many GPs and pharmacies and two AHSs (not included in consultations and/or data collection). Prior to the implementation of the ICDP, no DoGPs had an Aboriginal and Torres Strait Islander health program and no general practices were found to have Aboriginal and Torres Strait Islander staff.



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System capacity

General practice systemThere were several mainstream primary health care providers in the site; however, there was a strong perception from community members that access to GPs was actually very limited. Specialist services were accessible primarily through hospital clinics, and a limited number of private specialists were located within the site. Some AHPs were also located at hospitals, and others offered services through private practices. At baseline, a range of chronic disease related services were available through the two hospitals within the region. These secondary hospitals provided a range of chronic disease related services including diabetes education and management, cardiac rehabilitation, various specialist clinics and various allied health services including physiotherapy, social work and speech pathology. A larger and better equipped hospital was located between one and two hours’ drive away from the site. Neither of the two hospitals identified Aboriginal health as being a priority service area, which probably reflects the small proportion of the population. Neither hospital employed an AHLO at baseline. There were limited community health services and none were identified as providing chronic disease related services within the site at baseline.

Aboriginal and Torres Strait Islander service systemAt baseline, there were two AHS clinics (both satellite clinics of a single organisation) running limited primary health care services within the site and one Aboriginal Community Controlled Organisation (ACCO) providing community development and support programs, but not clinical primary health care. Information about the two clinics is limited as these services were not included in consultations and there is no publically available information about the services provided by the organisation. No OSR data is available for these services. At baseline the DoGP was in the process of setting up a dedicated Aboriginal and community and health service within the site (largely based on ICDP funded positions included an IHPO, ATSIOW and Care Coordinator). This was being done in consultation with local Aboriginal organisations and communities through a formal advisory body. The DoGP was not providing direct clinical service delivery, however programs like a women’s group, exercise groups and care coordinator were being established at the time of consultation. At baseline, the ACCO was not providing any primary health care or programs specifically addressing chronic disease. Some programs to encourage healthy lifestyles were had been implemented and community activities such as cultural walks and BBQs were occurring.


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Access Access to culturally appropriate care in this site seemed to be somewhat limited, with few primary health care services being provided by Aboriginal and Torres Strait Islander specific services. Possible reasons for this apparent disconnect include: Few GPs offer bulk billing services. Some GPs are not conveniently distributed within the area to allow easy

access for Aboriginal community members who may live in less affluent areas within the site.

The DoGP reported that many general practices do not believe they have any Aboriginal and Torres Strait Islander patients and see no imperative to review systems or implement policies to enhance access by Aboriginal and Torres Strait Islander people. There were no programs identified to enhance the cultural appropriateness of hospital services. The hospitals did not offer transport assistance, and access to public transport in the area was somewhat limited, although buses were available between service hubs and in the more densely populated areas. Given that most primary health care services were being provided by private GPs it is likely that cultural competence would vary significantly. Consistent with this, community consultations undertaken at baseline identified some concerns about the cultural competence of some GPs (see page 65 for examples and discussion).

Service coordinationWhile most primary health care were being provided by general practices, all other chronic disease related care were largely provided by the two hospitals. Service coordination between these two sectors would be highly dependent on individual providers and the referral and feedback pathways they had put in place, as well as personal networks; community members consulted identified service coordination as being particularly poor in this site. Overall, service providers reported at baseline that, the service system is only moderately effective in networking, service coordination, cooperation and collaboration, with the DoGP rating the system as 6/10 across all of these areas.182

Patient experience While the majority of preventive and chronic disease services were available within the site or in close proximity, individual community members identified barriers including cultural awareness and appropriateness of providers, waiting times, cost and access to transport. Other than the DoGP itself, no general practices were identified as having a strong interest in or commitment to Aboriginal and Torres Strait Islander health.

182 Based on a self-assessment questionnaire about effectiveness out of 10 against the domains: 1. networking 2. service coordination 3.cooperation and 4.collaboration


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It seemed that Aboriginal and Torres Strait Islander community members had very different experiences depending on which private GPs they primarily accessed.

PreventionThe key issues identified by community members in relation to prevention were: Many community members value a healthy lifestyle, however some people

are not motivated to make healthy lifestyle choices. Attitudes to smoking are changing and people are smoking less. Cost may be a barrier to participation in some healthy lifestyle activities.Community members reported that living a healthy lifestyle is seen as important and a priority for many. One of the biggest benefits of living in this region is apparently good access to lots of fresh produce including locally grown fruit, vegetables, meat and seafood.

‘We do have a healthy lifestyle. We do walking, land work, Zumba, gardening.’183

The community members who attended the focus groups spoke about keeping private veggie gardens, keeping chooks, bush walking and group exercise classes as part of their lifestyle.

‘People grow their own fruit and vegetables and we have the best fresh meat here! We are starting a community garden.’184

Smoking, unhealthy eating and physical inactivity, however, are big problems for some people in the community. Many Aboriginal and Torres Strait Islander people in this site have limited knowledge of traditional food sources. Even for those who do have some knowledge, access can be limited because hunting, gathering is not permitted on private lands, and some food sources may be protected in line with conservation principles.

‘Bush tucker is there if you know how... bush cherries, seafood, but sometimes you need permits and it can be expensive.’185

People spoke a lot about smoking and there was a strong perception that attitudes towards smoking have changed significantly in recent years, and the rate of smoking is decreasing in line with changing attitudes. While people identified public health promotion messages (e.g., television advertisements) as a driver in this change of attitude, people also reported that individuals have to be motivated to quit smoking, regardless of what message, information or services they are exposed to.

‘Yes, many still do but many are quitting.’186

183 Community member, site five.184 ibid.185 ibid.186 ibid.


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‘It’s no longer really seen as ok.’187

‘It’s a personal choice, people do it for lots of reasons, and they won’t quit until they are ready.’188

Community members had a good awareness of programs available to assist people to quit smoking, identifying both support services (such as Quitline) and pharmacotherapy based supports. Community members were aware of preventive health programs and activities available within the region, particularly healthy lifestyle programs available at the ACCO. Knowledge of and access to general practices was also good, although in some cases costs (such as gym memberships and sport registration fees) were identified as barriers. Community members also commented that while services are available, and people know how to access them, motivation for some people is very low because of social and mental health concerns.

‘Some people don’t get out and do any exercise because they are weighed down being sick all the time.’189

Diagnosis and treatment The key issues identified by community members in relation to diagnosis and treatment were: Some people have concerns about access to primary health care in the area

including the perceived quality of care and waiting times for various services. Many people only have access to mainstream primary health care, and many

mainstream providers were not seen to be providing culturally sensitive care or proactive chronic disease management.

Community members access primary health care through mainstream, private GPs in the area. Some people access the limited primary health care provided by the AHS, however there is a perception that not all community members are welcome at the AHS. Some community members reported high levels of satisfaction with their GP, stating that they had a long standing relationship and would continue to see that provider even if Aboriginal and Torres Strait Islander specific service became more widely available. Many people reported significant concerns, however, about access to primary health care in the area.

‘People have been going to their doctor for a long time, they don’t want to change... but if that GP isn’t interested in Closing the Gap [PIP Indigenous Health Incentive and PBS co-payment] then those people might not want to try to get into a new GP just to get the cheap scripts.’190

187 ibid.188 ibid.189 ibid.190 ibid.


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Community members reported that there are many overseas-trained doctors in the area and that they have limited understanding of Aboriginal and Torres Strait Islander health issues, and even many Australian trained doctors make little effort to relate to their patients in the context of their Aboriginality. Many people reported that their GP would probably not know or have recorded anywhere that they are Aboriginal.

‘There are so many overseas trained doctors here, it’s sometimes difficult to understand them or they might not understand how we can be Aboriginal but not have dark skin.’191

People were also concerned about the waiting times for various services, including to see their GP (most GPs use an appointment system and it can take up to a week for an appointment to be available), surgery waiting times within the public hospital system, and to access specialists (both public and private).

‘It’s hard to get to the doctor - long waiting lists, less and less bulk billing. If it’s at night or weekends they charge more too.’192

Most community members had not heard of the PIP Indigenous Health Incentive or CtG scripts, indicating that these programs had not been widely implemented at this site at the time of baseline consultations (November 2011). Many community members felt that providers do not provide supportive or proactive care, and felt that too much emphasis is placed on moving patients through the system without really understanding their concerns, providing good coordination or engaging in Aboriginal and Torres Strait Islander health programs.

‘It’s so hard to get in and when you do they just want to rush you out the door.’193

Finally, transport was identified as a barrier. For community members with access to private transport a wide range of services were readily available within a one or two hour drive. However, public transport is limited and taxis are too expensive for many people. The DoGP was providing some transport (being provided by the ATSIOW); however, this was not seen as sufficient to meet the needs of the community.Table 93 shows professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.



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740 449 76 9.7 5.9

Ongoing treatment and supportThe key issues identified by community members in relation to ongoing treatment and support were: Community members have a perception that access to ongoing treatment in

the primary health care space is limited by access to GPs, waiting times and transport.

Hospital based services also have long waiting times. Aboriginal and Torres Strait Islander specific services were limited at baseline.Community members’ experience of ongoing treatment and support largely reflect the discussion about diagnosis and treatment; community members are primarily reliant on their GP to provide or link them to treatment and support services. The concerns about access to transport for people without private transport are also very relevant to ongoing treatment and support.

‘Things are very far away and there is not much public transport available.’194

Community members generally reported that the hospitals in the area have a good range of relevant services, however waiting times can be long and cultural sensitively is perceived by many to be low. The exception to this seems to be ongoing support for diabetes patients. Community members with diabetes reported that they have access to many useful services and supports, and their ongoing management by both their GP and specialists was satisfactory. Finally, because almost all community members reported that they do not feel welcome at the AHS, the only Aboriginal and Torres Strait Islander specific support services are those provided by the DoGP and the ACCO. These organisations were offering a limited (but growing) set of services at baseline.

Baseline assessment Table 94 below draws together the information presented above about site five at the final stage. Against conceptual framework domain characteristics, this table provides the rating195 the evaluators gave the site at baseline.

194 ibid.190


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Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.



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Table 94: Assessment against the conceptual framework.Domains Characteristics

Rati

ng Assessment

System capacity


1 The site had limited Aboriginal and Torres Strait Islander-specific infrastructure, and primary health care services were somewhat limited. Mainstream secondary health services, however, were generally sufficient for the population base. The site had low engagement in core ICDP measures such as PIP Indigenous Health Incentive and the PBS co-payment at baseline.


1 The Aboriginal and Torres Strait Islander health workforce was fairly limited overall. ICDP workers had been recruited to most positions at baseline.


1 While there were a good range of services relative to the population, there was a strong representation that services were insufficient. The ICDP was adding services such as transport, which matched identified community needs.


1 Limited information indicated that this was likely to be highly variable.


2 The DoGP demonstrated a strong commitment to Aboriginal and Torres Strait Islander health and good engagement in the ICDP from senior leadership.

Access Services are geographically accessible to patients or support physical access e.g., through provision of transport or outreach.

1 Services were dispersed throughout the site, and community members identified transport and accessibility as key issues.

Services are financially accessible to patients. 1 Access to bulkbilling GPs or free primary health care through an AHS was limited at this site, and patients also reported that the costs

192



June 2014

Domains Characteristics

Rati

ng Assessment

associated with accessing many services (including transport and appointment fee) represent a barrier to accessing health care. Hospitals in the area do provide a range of relevant services and affordable services, however these may be insufficient to meet demand and culturally inappropriate according to some community members.


1 ICDP activity was mainly in place within the mainstream sector, and engagement in PIP Indigenous Health Incentive was limited. Access to the ICDP may therefore have been limited for some groups within the community. This was compounded by low awareness of ICDP initiatives such as PBS co-payment within this site.

There are protocols or mechanisms in place to support culturally appropriate care, such as inclusion of family members in appointments and decision making.

1 There was limited evidence of this within general practices.


1 There was limited evidence of cultural awareness training being undertaken other than by practices registered for PIP Indigenous Health Incentive.


1 This was limited other than within the DoGP, which employed Aboriginal and Torres Strait Islander staff.


1 This was limited, other than Aboriginal and Torres Strait Islander staff working at the DoGP in the new Aboriginal health team.


1 This was limited other than within the DoGP, which employed Aboriginal and Torres Strait Islander staff.

Service coordinatio

Networking, cooperation and information sharing between services relating to patient care is occurring

1 This was largely informal and facilitated through personal networks. Community members reported that coordination was poor.

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June 2014


Rati

ng Assessment

n There is a focus on patient-centred planning and care delivery involving multiple providers


Informal mechanisms or practices that support service coordination and patient-centred planning and care delivery (e.g., referral protocols, service directories, cross-agency awareness training) are in place

1 There was some limited evidence of informal mechanisms and practices facilitated by individual relationships across key providers.

Formal mechanisms or practices that support service coordination and patient-centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co location of services, shared information systems and joint planning) are in place


Services within the system are complementary and there is no duplication

2 Services were not found to be creating duplication.

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June 2014

Changes expected to occur as a result of ICDP at baselineIn the baseline year, the DoGP had ICDP funding for an ATSIOW, IHPO and Care Coordinators. At baseline, the following changes were expected as a result of the ICDP. At the time of baseline consultations, approximately 25 per cent of general

practices had signed up for PIP Indigenous Health Incentive. The IHPO was expected to improve PIP Indigenous Health Incentive registrations within the site and build cultural awareness within the mainstream health sector. The DoGP, however, reported significant challenges in actually getting GPs to identify their Aboriginal and Torres Strait Islander patients and then to undertake health check and care planning. This was expected to result in limited further uptake of the PIP Indigenous Health Incentive, provision of care associated with Tier 1 and 2 payments, and access to the PBS co-payment.

At baseline, there were no mainstream care coordination services available to Aboriginal and Torres Strait Islander patients. The CCSS was a new service provision that was expected to improve the coordination of care for individual patients, build relationships between the mainstream and ACCHO and collaborate in multidisciplinary teams. Improved access to culturally safe specialist care was expected to result from the additional specialist services provided the MSOAP-ICD.

The ATSIOW was expected to improve access to services through the provision of additional transport to Aboriginal and Torres Strait Islander patients in need, and by providing support for these patients, when requested, during clinical consultations.

3.5.2 Site five at final At the final stage, the key characteristics of the site remained much the same, that is: the Aboriginal and Torres Strait Islander community was dispersed amongst

several small and medium size towns in the site; health services were primarily provided by a variety of mainstream

organisations; the site was considered to be a district of workforce shortage for general

practices; and the site continued to have the lowest proportion of patients registered for PIP

Indigenous Health Incentive of all sites. At baseline, the main ICDP funded mainstream organisation was a DoGP. In November 2011, this DoGP merged with three other DoGPs to form the Medicare Local.


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ICDP workforce investment and activity at site fiveTable 95 below shows the number of ICDP workers allocated to the Medicare Local by final stage.

Table 95: ICDP workforce allocation (FTE) within site five, 2012-13 (various dates).196

Position ML Total Allocation

CC 1.6 1.6IHPO 1.0 1.0ATSIOW 1.0 1.0Total 3.6 3.6

ICDP workforce investment in the Medicare LocalCtG team (IHPO, ATSIOW and Care Coordinators): The ATSIOW, Care Coordinators and IHPO in the Medicare Local work closely together as part of a CtG team. The team members have been employed for between six months and two years. There has been no staff turnover.

‘There is a strong sense of ownership amongst the team members and our program is well developed. This makes the model sustainable and the workforce very stable.’197

The team structure ensures the CtG team’s ‘clients’ are seen by the most appropriate worker and thus receive the correct level of care. For example, if a patient requires transport assistance, they will only work with the ATSIOW, regardless of whether they are a CCSS patient. Having multiple staff within one team supports responsiveness because, if one worker is not available, another may be. A community needs assessment underpins this model. It showed that the key barriers were financial (e.g., costs of appointments) transport, and inability to navigate the service system.

‘We have a model that is able to provide integrated services to the community. All of our Aboriginal and Torres Strait Islander specific services are located within the same building. This means that people come here for all sorts of reasons and they are willing to come to see the Care Coordinators and they are engaged with the CtG program.’198

The IHPO manages the team, and worked closely with local practices and the community to promote ICDP programs and increase cultural awareness through providing information and training. The IHPO has also moved towards community education in preventive health through the organisation of community events. 196 Workforce data provided by the former Department of Health and Ageing. Note there are different datasets for each worker type, and each provide point in time snapshots at dates within 2012-13. 197 Consultation with IHPO, site five, 2013.198 Consultation with Medicare Local staff, site five, 2013.


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The focus of the ATSIOW was to facilitate access to health care for clients and to link community members and services together. This was achieved through the provision of transport, making appointments, and providing other supports to address client needs. The two Care Coordinators each work part-time. They generally work with clients who have multiple complex needs, in partnership with the ATSIOW and MSOAP-ICD providers, until their chronic disease is under control. MSOAP-ICD: The Medicare Local also facilitates a team of MSOAP-ICD professionals who provide outreach specialist care to Aboriginal and Torres Strait Islander chronic disease patients on a periodical basis. The program was supported by administration arrangements provided by the Medicare Local, enabling the facilitation of access for Aboriginal and Torres Strait Islander people to specialist outreach services.The MSOAP-ICD Specialist visiting the site included a Psychologist (fortnightly), an Exercise Physiologist (monthly), a Dietician (monthly) and a Podiatrist (monthly). Care is delivered from within the CtG program facility, allowing the providers to work closely with the Care Coordinators on site. Each specialist had completed cultural awareness training.

Impact of the ICDPEach of the changes expected to occur as result of ICDP investment were found to have occurred at the final stage. These expected changes were: An increase in PIP Indigenous Health Incentive practice participation and

associated improvements in the cultural competency of general practices. Improved access to pharmaceuticals through enhanced access to the PBS Co-

payment. Improved access to care coordination and general patient support. Improved access to specialists and allied health services. Additional transport services.In addition to these expected changes identified at baseline, several other impacts were also observed. Overall, the key changes as a result of ICDP investment at this site, with reference to the conceptual framework, were: system capacity: an expanded health workforce, availability of new and

additional health services that were not previously available; access: improved geographical accessibility and cultural accessibility for

patients, leading to increased level of access to services; and service coordination: some improved information sharing and coordination

across service levels within the Medicare Local and between the Medicare Local and the ACCHO and AHPs.



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Changes to system capacityThe services provided through the Medicare Local expended are illustrated in Table 96 below.

Table 96: Summary of chronic disease-related services provided by the Medicare Local in site five at 2009 and 2013.199

Service provided by the ML 2013

Diabetes education YesChronic disease care coordination YesNutrition and dietetics YesExercise physiology YesMental health services YesChronic disease awareness education (for community)

Yes

Cultural awareness education (for practitioners) Yes

All ICDP investments in site five represent new Aboriginal and Torres Strait Islander-specific health services that align with community need: The CtG program is the first Aboriginal and Torres Strait Islander health

program within the Medicare Local (or the DoGP prior to the transition);.the ICDP funded CtG health workforce formed a strong and stable team with a high level of ownership for the CtG program.

The CtG health workforce (IHPO, CCs and ATSIOW) within the Medicare Local were the first Aboriginal and Torres Strait Islander staff employed.

The ATSIOW provided much needed transportation for Aboriginal and Torres Strait Islander patients, although this service remained insufficient to meet the high level of need within the site.

The CCSS and MSOAP-ICD represent new sources of funding for access to care coordination, and specialist and allied health services and medical aids. The financial barriers to these services for patients in this site were significant, while:- There were some specialist and allied health services available for free

through the AHS at baseline, not all Aboriginal or Torres Strait Islander patients could access this service.

There was no data available on the number of services providing care to Aboriginal and Torres Strait Islander clients pre-ICDP.

Through an increase in the number of mainstream health organisations offering programs and services to Aboriginal and Torres Strait Islander people, the ICDP has facilitated greater patient access. 199 Based on information gathered online.


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Changes to accessibilityThe ICDP has increased both physical and cultural accessibility of services in the region. New GPs were required by the Medicare Local to undertake cultural

awareness training (conducted by the IHPO), however, the proportion of GPs who engaged in training is not known.

The IHPO worked with local practices to increase their cultural appropriateness. This included a focus on Aboriginal and Torres Strait Islander identification, building awareness of Aboriginal and Torres Strait Islander-specific MBS items and ICDP initiatives such as CtG scripts and the PIP Indigenous Health Incentive. This has been a difficult process as many GPs have difficulty understanding that the community they provide services to include Aboriginal and Torres Strait Islander people whose needs may differ from those of the general population.

The IHPO engaged with the Aboriginal and Torres Strait Islander community through organising community events (e.g., CtG Day and National Aboriginal and Islander Day Observance Committee (NAIDOC) week events). This increased the community’s awareness of ICDP services and programs, such as the CtG team, MSOAP-ICD providers, PIP registered health professionals, CtG scripts, and healthy lifestyles.

The CCs helped to reduce the barrier to specialist care by providing Aboriginal and Torres Strait Islander patients with care coordination and referral to appropriate GP providers and specialist care services (including those provided by the MSOAP-ICD).

‘The CCs are really good. They are very helpful and a great source of information about how to take care of yourself and what services are available, what to ask for and how to access them. They provide us with support, including moral support and lots of information. Yes, the most valuable thing they provide is knowledge about health. They also call and check in with people, see how they are going and whether they need anything.’200

The work of the ATSIOW addressed many of the barriers to accessing health care. This included a lack of transport, limited knowledge of the available services within the region and a lack of culturally appropriate support when attending mainstream health professional appointments.

‘We have good access to allied health here for people with chronic diseases and the best way to access them is through the CCSS program. People there are more aware of different health workers and how to access them.’201

200 Consultation with Aboriginal and Torres Strait Islander community member, site five. 2013.201 ibid.


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The number of PIP Indigenous Health Incentive registered patients is illustrated in Table 9797 below. Less than one fifth of the Aboriginal and Torres Strait Islander people in this site were EverIHI as at 2011. This low representation reflects current attitudes of general practices, who mistakenly believe that they do not provide health care to Aboriginal or Torres Strait Islander people.


992


19.15%

Prior to 2009-10, EverIHI patients at site five effectively did not receive Health Assessments. This changed substantially from the second half of 2010, with meaningful growth in both the numbers of Health Assessments and the number of providers thereof (Table 98 and Table 99). There was also meaningful growth in the numbers of allied health follow-up services after June 2010, in line with the observed growth in the numbers of Health Assessments (Table 100). This growth resulted in there being 41 follow ups per 100 EverIHI patients in 2012 (Table 101).There was no change in either the numbers of attendances at specialists or in the number of specialist providers (Table 102102). Similarly there was no change in the number of specialist attendances per 100 EverIHI patients (Table 103103).Numbers of GP attendances were increasing prior to the baseline year but slowed their increase after then (Table 104104). At the same time, numbers of GPs were stable, resulting in increased average attendances per GP. This continued increase resulted in the number of GP attendances per 100 EverIHI patients increasing from 981 in the baseline period to 1,205 in 2012 (Table 105105).There were also quantum increases in pathology tests for EverIHI patients at site five, in December 2010 and again in December 2012 (Table 106106). In 2009-10 100 EverIHI patients at site five received on average 577 pathology tests. By

202 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra.203 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.204 MBS data supplied by the former Department of Health and Ageing, 2013.205 This is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period. As such, the patients (EverIHI) values may not always match the numbers in the proceeding tables.


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2012 this had increased to 750 pathology tests per 100 EverIHI patients (Table 107107).These findings suggest some changes to the patient journey for EverIHI patients at site five, centred on increased Health Assessments, allied health follow up services and pathology tests for EverIHI patients. While there was no observed change in use of specialist attendances as a result of the increased monitoring and follow up for EverIHI patients, there was substantially increased use of GP services for EverIHI patients. It is not clear whether these two findings are related or not.

Table 98: Numbers of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments and average Health Assessments per provider206, site five, by six month period, 2007 to 2012.207

Six months ending




June 2007 - - -December 2007 1 1 1.0June 2008 - - -December 2008 1 1 1.0June 2009 1 1 1.0December 2009 - - -June 2010 4 2 2.0December 2010 2 2 1.0June 2011 23 9 2.6December 2011 19 14 1.4June 2012 36 22 1.6December 2012 23 18 1.3



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Table 99: Number of EverIHI patients, Health Assessments and Health Assessments per 100 EverIHI at site five in 2009-10 (baseline period) and calendar year 2012.208

Statistic 2009-10

2012


2 32

Table 100: Numbers of allied health follow up services209 for EverIHI patients at site five, by six month period, 2007 to 2012.210

z Allied health follow-up services

June 2007 2December 2007

1


9


12


25


24


36

208 ibid.209 MBS subgroup M03—Allied Health Services plus MBS subgroup M11--Allied Health Services For Indigenous Australians Who Have Had A Health Check.210 MBS data supplied by the former Department of Health and Ageing, 2013.


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Table 101: Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site five in 2009-10 (baseline period) and calendar year 2012.211

Statistic 2009-10

2012


408 69

Table 102: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site five, by six month period, 2007 to 2012.212

Six months ending

Attendances

Providers Attendances per provider


211 ibid.212 ibid.


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Table 103: Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site five in 2009-10 (baseline period) and calendar year 2012.213

Statistic 2009-10

2012


58 54

Table 104: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site five, by six month period, 2007 to 2012.214

Six months ending


June 2007 681 92 7.4December 2007 688 83 8.3June 2008 709 93 7.6December 2008 658 84 7.8June 2009 809 157 5.2December 2009 876 116 7.6June 2010 987 84 11.8December 2010 1,063 112 9.5June 2011 1,065 118 9.0December 2011 1,099 107 10.3June 2012 1,131 110 10.3December 2012 1,123 105 10.7

Table 105: Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.215

Statistic 2009-10

2012



981 1,205



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Table 106: Numbers of pathology services for EverIHI patients at site five, by six month period, 2007 to 2012.216

Six months ending

Pathology services


Table 107: Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.217

Statistic 2009-10

2012



577 750

As noted above, site five had lower numbers of PBS scripts dispensed to EverCtG patients than the other regional sites. It seems likely that this is associated with the relatively low uptake of PIP Indigenous Health Incentive in this site. 108 below shows the number of PBS scripts dispensed to EverCtG patients between 2007 and 2012.

216 ibid.217 ibid.


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Table 108: Number of PBS scripts dispensed to EverCtG patients by six month period, site five, 2007 to 2012.218

Six months ending

Scripts


The number of scripts per patient at sites five and six were also similar. At site five, the number of scripts per patient in the six months ending December 2012 (15.2) was higher than at the other sites such as urban site one (11.7) and regional site four (11.7).

Changes to service coordinationAs at baseline, primary health care was being provided by general practices, and all other chronic disease-related care was largely provided by the two hospitals. Service coordination between these two sectors remained dependent on individual providers and the informal referral and feedback pathways they had put in place, as well as personal networks. The ICDP funding allowed the Medicare Local to deliver patient-centred coordinated care and outreach services to some patients from within the target community. The Care Coordinators were able to improve the management of chronic disease through supporting patients, case management and providing follow up care. One Care Coordinator was trained in Flinders CtG CDSM, and was accredited and provided CDSM sessions to their patients. The ATSIOW provided some linkage between the Medicare Local and local allied health workers and specialists; and the IHPO worked with local GPs to promote awareness of Aboriginal and Torres Strait Islander needs, the PIP Indigenous Health Incentive and CtG scripts. While stronger linkages were being formed between the Medicare Local and the ACCHO, and attempts were made by the 218 Pharmaceutical Benefits Scheme data. Provided to KPMG by the Department of Health, 2013.


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Medicare Local to improve levels of collaboration, there remained very little cooperation or information sharing across the mainstream and Aboriginal and Torres Strait Islander health sectors.

‘There is not much coordination between mainstream and Aboriginal health sectors. The AHS has been non-collaborative with us and we are still finding it very difficult to work with them, although we have occasionally made some progress.’219

‘GPs don’t provide us with feedback; they don’t engage with us.’220

The transition from the DoGP to the Medicare Local was disruptive within site five. As management structures were adjusted within the Medicare Local, these changes negatively affected the coordination of ICDP services and programs, and slowed the organisation’s decision making processes.

‘There was a real lag in decision making which impacted on us being able to get on and do things. No one knew what was happening and it was confusing.’221

‘There was a perception in the community that the Medicare Local had come in to ‘take over’ services and people were anxious about that’.’222

There was, however, also a perception within the Medicare Local that, since the change, the organisation was more able to meet the needs of Aboriginal and Torres Strait Islander patients. It was reported by ICDP staff that this gave them more opportunities to access funding to deliver more community and patient-focused programs.

Impacts of ICDP on patient experience

The most significant improvements to the patient journey at this site can be linked back to improved availability of culturally appropriate mainstream primary health care and improved access to transportation.The following changes to the patient journey were noted: Increased health care infrastructure and health workforce capacity. The

establishment of the CtG team within a dedicated facility, which was supported by MSOAP-ICD practitioners, increased the availability of culturally appropriate care to Aboriginal and Torres Strait Islander people within the community.

Increased access to health care services. The ATSIOW improved Aboriginal and Torres Strait Islander access to health care services by providing transportation, interpretation of medical information and other supports. The MSOAP-ICD provided specialist services to Aboriginal and Torres Strait Islander chronic disease patients at no cost.

219 Consultation with IHPO, site five. 2013. 220 Consultation with Care Coordinator, site five. 2013. 221 Consultation with Indigenous Health Project Officer site five. 2013222 Consultation with Care Coordinator, site five. 2013.


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Increased awareness of healthy lifestyles and health services amongst Aboriginal and Torres Strait Islander patients. The IHPO and ATSIOW worked at the community, practitioner and patient level to increase local awareness of the ICDP and related health services.

‘People are more aware of different workers and how to access them.’223

Increased availability and delivery of cultural awareness training. The IHPO delivered cultural awareness training to MSOAP-ICD practitioners, PIP Indigenous Health Incentive registered GPs and new GPs within the site.

Improved cultural ties to the patient group. The CtG team consists of Aboriginal staff who have begun to form cultural ties to the local community. These ties were being strengthened by the ATSIOW, through their continued presence within the community, and the IHPO, through their delivery of Aboriginal and Torres Strait Islander community events.

Increased availability of patient-centred coordinated care. Care coordination was provided to Aboriginal and Torres Strait Islander patients by CtG program. Care Coordinators represented a new service that was not available to many patients at baseline. One Care Coordinator applied the tools and principles of Flinders CtG CDSM to their patients.

Ongoing challenges related to ICDPThree key barriers were evident at site five at final stage, as outlined below. Limited understanding of Aboriginal and Torres Strait Islander health needs

amongst mainstream providers. The strength of the impact on improved cultural awareness amongst general practices was significantly limited. This was due to the consistent and adamant belief amongst many GPs that they do not provide services to Aboriginal and Torres Strait Islander people, and their reluctance to identify existing Aboriginal and Torres Strait Islander patients within their practices.

‘There are lots of overseas doctors here. It can be hard to understand what they are saying and what they are asking. People get frustrated with this and might think it's not even worth going to the doctor.’224

Geographical isolation and poor availability of transport. While additional transport was provided by the ATSIOW, this was not adequate to meet a high level of need within the community for this service.

‘Transport is the biggest barrier to people. It has improved a little but the ATSIOW can’t take everyone all the time.’225

‘Sometimes you get extra money to help with transport if you have to go far away, but not always. People still have to go to [regional city] for many specialists and some tests and treatments. Sometimes they even have to

223 Consultation with Aboriginal and Torres Strait Islander community member, site five, 2013.224 ibid.225 ibid.


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go all the way to [capital city], but most things are in [regional city]. This hasn't changed at all.’226

Poor levels of collaboration between services and health care sectors. Although strong relationships were built between Care Coordinators, MSOAP-ICD professionals and the ACCHO, this did not transfer to general practices or the AHS.

3.5.3 Final assessmentTable 109109, Table 110110 and Table 111111 below draw together the information presented above about site five at the final stage. Against conceptual framework domain characteristics, this table provides: the rating the evaluators gave the site at baseline227; the rating the evaluators gave the site at final stage228; the key changes observed; and what these changes appear to be attributable to.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.Figure 9 and Figure 10 below provide a visual representation of the findings within this chapter as at baseline and as at the time of the final evaluation. Each figure is presented as a systems map which details, on a single page, the health services provided within the community, primary, secondary and tertiary sectors within the site. Each patient services map includes the: AHS and mainstream services/supports located within the site; ICDP staff and programs (post-ICDP map only); linkages between services, where these are in place; and identified facilitators and barriers to patient accessibility to these services.

226 Ibid.227 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory. 228 0 = not in place. 1 = in place but insufficient or incomplete. 2 = in place and satisfactory/moderate change from a low base. 3= notable change from baseline.


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1 2 There has been an expansion of mainstream health service infrastructure. The Medicare Local opened a new Aboriginal and Torres Strait Islander-specific health service within the region in collaboration with the local ACCHO. A new Super Clinic also opened within the region in mid-2011. The clinic provides the community with general practice services, chronic disease management (including Indigenous Health Checks), and allied and specialist health services (e.g., Diabetic services and Mental Health). GP engagement in core ICDP measures (PIP Indigenous Health Incentive and the PBS co-payment scheme) increased, although this remains comparatively low.

The ICDP funded one IHPO, two (0.8 FTE) Care Coordinators, one ATSIOW and a number of MSOAP-ICD providers who delivered services from the Medicare Local. The IHPO promoted and supported practices to participate in ICDP programs such as PIP and CtG scripts.


1 2 Waiting times for GP appointments are no longer a major issue within the region. Reduction in waiting times may be a reflection of increased workforce capacity, such as the opening of the Super Clinic. The Aboriginal and Torres Strait Islander health workforce remained fairly limited overall.

ICDP funding provided some extra primary (care coordination) and secondary (MSOAP-ICD) health services within the site and this may have contributed to the alleviation of waiting times.


1 1 While needs assessments were conducted by the IHPO, the communication of patient and community needs remains within the early stages of development. It was reported by all ICDP staff and the Medicare Local that many GPs continue to disbelieve that Aboriginal and Torres Strait Islander patients are present within their

The IHPO conducts needs assessments on a regular basis (as per contracted) and promotes these needs to local GPs. The Care Coordinators and ATSIOW have worked towards ensuring that patients’ needs are understood and addressed as they arose.

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community and are often disinterested in this groups’ specific health and cultural needs. Dental care was identified by the Medicare Local and the community as a major need that was not being met. Dental care remains out of reach for many patients due to high costs and/or very long waiting times. Transport also remains a major barrier for many patients. Although some patients’ transport needs were addressed by the employment of an ATSIOW staff member, this did not meet the existing level of demand.


1 1 Limited information indicates that this has remained highly variable.

Not applicable.


2 2 The Medicare Local demonstrated a strong and sustained commitment to Aboriginal and Torres Strait Islander health and a high level of engagement in the ICDP.

Funding provided to the Medicare Local supported the organisation’s commitment to Aboriginal and Torres Strait Islander health by enabling them to deliver culturally appropriate patient and community centred services.

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Services are geographically accessible to patients or support physical access e.g., through provision of transport or outreach.

1 1 Services are dispersed throughout the site. Although some additional transportation became available, community members continued to identify transport as a key issue. Due to distance, some patients are not able to access Aboriginal and Torres Strait Islander services within the Medicare Local.

The ICDP funded one ATSIOW to provide transportation to Aboriginal and Torres Islander patients in need.


1 1 Access to specialists and allied health providers has improved for small number of patients through CCSS and MSOAP-ICD. Uptake of CtG scripts is relatively low in this site; however for some patients this measure has made medication more affordable. Transport provided by the ATSIOW has also improved financial accessibility for patients with limited access to private transport or affordable public transport.

Although the changes noted are minor, ICDP programs have somewhat reduced financial barriers (CtG scripts, CCSS, MSOAP-ICD, ATSIOWs).


1 2 Since baseline, there are now more services available that target the needs of Aboriginal and Torres Strait Islander patients, who also have a greater awareness of these services. While the number of PIP registered GPs within the site remains relatively low, greater numbers of community members were identified as Aboriginal and Torres Strait Islander patients by general practices participating in PIP. Once identified, these patients became more aware of

The ICDP funded new Aboriginal and Torres Strait Islander-specific services within the Medicare Local. PIP participation and CtG scripts has improved some practices’ understanding of the need to tailor to Aboriginal and Torres Strait Islander patients.

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and more connected to other services.There are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments and decision making.

1 2 Culturally appropriate health care became more available within the mainstream sector through the Medicare Local. The establishment of the dedicated Aboriginal and Torres Strait Islander clinic within the Medicare Local improved the level of support for culturally appropriate care. The Medicare Local worked towards supporting GPs in improving their cultural awareness by conducting periodical visits to established GP practices and by delivering cultural awareness training to all new practitioners within the site.

The ICDP supported, through funding, the establishment of a dedicated Aboriginal and Torres Strait Islander health service with embedded protocols and mechanisms to support culturally appropriate care. The ICDP funded the Medicare Local to deliver cultural awareness training as a part of the orientation process for new GPs within the site, and to promote cultural awareness and ICDP measures to established general practices.


1 2 Steps were taken by the Medicare Local to ensure that a culturally appropriate environment was available and accessible. The Medicare Local’s Aboriginal and Torres Strait Islander-specific health service offered an appropriate environment for patients. This service did not, however, include GP services. A limited number of general practices undertook cultural awareness training.

The ICDP funded the employment of culturally aware staff (IHPO, Care Coordinators and ATSIOW) who provided a culturally appropriate service and health care environment. The ICDP funded the Medicare Local to deliver cultural awareness training as a part of the orientation process for new GPs within the site. The IHPO promoted cultural awareness and the ICDP measures (PIP and CtG scripts) to established general practices.


1 1 Limited other than within the Medicare Local, which established a dedicated Aboriginal and Torres Strait Islander health service. The Medicare Local worked extensively with GPs to increase their understanding of their need to

The IHPO promoted cultural awareness and ICDP measures (PIP and CtG scripts) to GPs. The ICDP funded the Medicare Local to deliver cultural awareness training as a part of the orientation process for new GPs within the site.

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identify patients and improve the cultural appropriateness of their services. While a few practices became engaged with the ICDP, this occurred with limited overall success. There remained reluctance amongst most general practices to adapt their practices to support their Aboriginal and Torres Strait Islander patients.


1 2 There were greater cultural ties between the mainstream Medicare Local health workforce and the patient group. This included the employment of local Aboriginal or Torres Strait Islander staff, the establishment of an Aboriginal and Torres Strait Islander dedicated health service and involvement in local community events. There was no evidence of cultural ties between other members of the mainstream health workforce and the patient group.

The ATSIOW was instrumental in assisting the Medicare Local to strengthen links with the local Aboriginal and Torres Strait Islander community. The IHPO organised a number of community events. The Aboriginal and Torres Strait Islander dedicated health centre became a service hub within the site and attracted members of the community.


1 2 Access to cultural awareness training improved within the mainstream health workforce.

The Medicare Local introduced cultural awareness training, funded under the ICDP, for all new GPs within the region and provided this training to some staff. The MSOAP-ICD organisation delivered cultural awareness training to all of their providers.

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1 1 A high level of networking, cooperation and information sharing occurred within and between the Medicare Local and ACCHO. There remains very little information sharing between the Medicare Local and other services within the site, who continue to use personal networks and largely informal processes. The Medicare Locals reported that, despite their attempts to improve levels of communication, cooperation and information sharing between themselves, other general practices and the AHS remained poor.

ICDP funded workers, ICDP funded MSOAP ICD providers and the ACCHO work closely, share information and refer patients to each other. The IHPO and Care Coordinators continue to attempt to form networks with local GP practices and the AHS.


1 1 Patient-centred planning and care delivery involving multiple providers now occurs within the Medicare Local. There was no evidence of change in client-centred planning within the mainstream health workforce since baseline.

The ICDP funded Care Coordinators and MSOAP-ICD providers have together improved care planning and delivery of services through multidisciplinary teams.


1 1 Informal mechanisms within the Medicare Local improved service coordination and patient-centred planning and care delivery. There was little evidence of change within the mainstream health workforce since baseline.

The ATSIOW referred patients to the Care Coordinators. The Care Coordinators referred patients to the MSOAP-ICD practitioners and GPs who were registered PIP providers.

Formal mechanisms or practices 1 1 The shared physical space and team structure The ICDP supported, through funding, the

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that support service coordination and patient-centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, shared information systems and joint planning) are in place.

at the dedicated Aboriginal and Torres Strait Islander health service within the Medicare Local facilitated the integration between health service providers. There remained limited evidence of any other forms of patient-centred planning or care delivery across mainstream and Aboriginal and Torres Strait Islander health providers since baseline.

establishment of a dedicated Aboriginal and Torres Strait Islander health service at a single site (separate from the Medicare Local building).


2 2 Services were not found to be creating duplication.

Not applicable.

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Site five (SSE) pre ICDP – patient journey map

Com

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Terti

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ICDP linkage

Non-ICDP linkage



Facilitator

Barrier

HEAL

TH C

ARE

SETT

INGS

Ongoing access

Ongoing access

Referral

Ongoing access

Ongoing access

Coordination

Coordination

Referral

Transportation

City based hospital services

(including Dialysis)


Welfare

Education

Cost of medication when travelling not

covered by S100 arrangements

IHS

Intermittency of programs

Staff turnover

Lack of accommodation for visiting staff

Accessible within

community

Dietician and diabetes education

Housing


Limited access to healthy food

options

Medication S100 supply

arrangements

Regional based hospital services

(including dialysis)

Lack of capacity to provide some

specialist services at

community level

IHS

Employment

Long waiting times

Time away from community

Limited support for

individualised engagement

in change


(including Dialysis)Transportation



(including dialysis)Time away from

community

Transport provided

Focus on acute demands

IHS Healthy for Life program

Health promotion programs

Support Services

Limited capacity for CDM

Ongoing access

Telephone GP consultations

Lack of program focus on

young people


ICDP staff/program

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Figure 9: Patient service map site five: Baseline. Source: KPMG.

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Site five (SSE) with ICDP – patient journey map

Com

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ICDP linkage

Non-ICDP linkage



ICDP staff/program

Facilitator

Barrier

HEAL

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SETT

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*ICDP facilitator


Ongoing access

Ongoing access

Referral

Ongoing access

Ongoing access

Patient access

and CareCoordination

Coordination

Coordination

Referral

Transportation


(including Dialysis)


Welfare

Education

ATSIOW (C2)

Cost of medication when travelling not


IHS

Intermittency of programs

Staff turnover

RTSHL Lack of accommodation for visiting staff

Accessible within

community


Housing


Limited access to healthy food

options

Medication S100 supply

arrangements

Transportation*

Access to medication through CtG

scripts*



Lack of capacity to provide some

specialist services at

community level

IHS

Employment

Program Manager

Additional Health Staff

Long waiting times


Limited support for

individualised engagement

in change


(including Dialysis)Transportation




Links with RTSHLT*


Care Coordinator

Transport provided

Focus on acute demands

IHS Healthy for Life program

Transportation*


Support Services

Limited capacity for CDM

Ongoing access

Telephone GP consultations

Lack of program focus on

young people

Figure 10: Patient service map site five: Final. Source: KPMG.

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3.6 Site six (very remote)3.6.1 Site six at baseline This site covers two LGAs; however, the majority of consultation was undertaken in the regional centre where most services are concentrated. The site covers a large geographical area of over 87,000 square kilometres and the primary industry is agriculture. The population, including the Aboriginal and Torres Strait Islander population, is concentrated in the regional centre and two or three other small towns. At baseline, this area was considered an area of workforce shortage for general practice. As a remote area with a small population dispersed over a large geographical area, access to health services was very limited and many services were unavailable in the local area. The service system capacity was inhibited by the limited availability of providers and the need for patients to travel large distances to access many services. All health services agreed that the limitations were exacerbated by difficulty recruiting and retaining suitable staff to the available positions. Table 112112 provides summary statistics for site six, covering the local population profile, participation in the PIP Indigenous Health Incentive and conduct of Health Assessments.


Indicator StatisticEstimate Resident Population (2011 Census) 6,477Aboriginal/Torres Strait Islander population (2011 Census) 1,104Proportion of Population identifying as Aboriginal and Torres Strait Islander

17%


156


14.10%


28

Site six includes three hubs, three hospitals, a small number of GPs and pharmacies, and an AHS that provides outreach. Prior to the implementation of the ICDP no DoGPs had an Aboriginal and Torres Strait Islander health program



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and no general practices were found to have Aboriginal and Torres Strait Islander staff.

System capacity

General practice systemAt baseline, there was only one private GP in the town, and several Aboriginal and Torres Strait Islander people were accessing this GP. There were visiting GP arrangements in place in at least two smaller towns with the site, and these were being provided by state-funded GPs at the time of consultation. There were three small hospitals and one outpatient clinic at the site. The larger hospital provided a range of permanent and visiting specialist services including general medical, emergency medicine, dialysis and various allied health services. A larger and better resourced hospital was found to be located around 260 kilometres from the regional centre, and the nearest tertiary hospital was located over 800 kilometres away. There were no permanent specialists located at the site, and very few AHPs. People were often required to travel long distances to access services. Other than basic aged care services, there were no community health or council run services identified during the consultation period.

Aboriginal and Torres Strait Islander service systemThe AHS was found to be well established and providing primary health care from a clinic within the regional centre and from three satellite clinics in smaller towns (outside of the boundaries specified for this site). One of the greatest challenges faced by the AHS was a reliance on visiting doctors who provided limited services (half a day a week at time of consultations). This represented a significant limitation on the capacity of the organisation to provide comprehensive primary health care. A strong nurse led model was in place during the baseline site visit, in addition to a small number of specialist and allied health visiting services (including some MSOAP-ICD funded services). In 2011, the AHS relocated to a new purpose-built facility, which will greatly enhance their capacity to provide a broader range of services by visiting specialists and AHPs and a more extensive range of community programs in the future.In 2009-10, the AHS reported through the OSR that they had total of 51 staff – five of which were doctors, seven were specialists or AHPs and 14 were AHWs. In addition, the AHS was hosting 1.2 visiting specialists. It should be noted that the staff numbers reported for the 2009-10 financial year do not reflect the information gathered during consultations, particularly with regard to the number of doctors employed by the service. A total of 5,280 episodes of care were provided in 2009-10 (3,185 to Aboriginal and Torres Strait Islander patients). The majority of client contacts (total 8,848)


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were AHWs (3,380), followed by specialists/AHPs (1,739) and nurses (1,652). Doctors provided only 474 client contacts in 2009-10.A second AHS was found to be located with the site boundaries. This service was also reliant on visiting GPs, but did provide some permanent chronic disease related services including diabetes education and chronic disease management support. Limited consultations were undertaken at this site, and ongoing reference within this section will refer to the first AHS described above. Table 113113 below provides a summary of chronic disease related services provided by the AHS in site six AHS in 2009-10.

Table 113: Summary of chronic disease related services provided in site six.Summary of chronic disease related services provided by the AHS in site six in 2009-10

Yes/No

Management of diabetes YesManagement of cardiovascular disease NoManagement of other chronic illness NoService maintains health registers NoShared care arrangements for management of chronic disease NoChronic disease management groups YesTobacco use treatment/prevention groups No

Access At baseline, the one private GP reported that they were at capacity and unable to take on any new patients (either Aboriginal and Torres Strait Islander or non-Aboriginal and Torres Strait Islander). Community members generally reported that this provider was considered to be culturally appropriate – just difficult to access due to capacity constraints. The AHS had developed a cultural awareness package for its own staff and was also providing this training to staff at the hospital. Some community members consulted reported some concerns about cultural safety at the hospital, while others reported that the hospital staff are generally seen as culturally appropriate. People reported mainly positive experiences accessing all health services in the area, including the AHS, private GP, hospital and pharmacies. The AHS in this site was the only AHS across the six sites that reported providing afterhours services in 2009-10; these services related to transport.

Service coordinationThe AHS reported good working relationships with the local private GP and the local hospital. The local private GP also reported a positive relationship with the AHS. The DoGP (which had a very large service area) had limited interactions


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with the AHS, although both organisations reported that the relationship was positive at baseline. It was noted that because of the limited access to GPs across all service providers many Aboriginal and Torres Strait Islander people were accessing multiple services depending on availability at any given time – particularly a combination of the AHS and the hospital. This made it more difficult to coordinate care for patients with chronic disease. The AHS and hospital were managing this through a schedule of continuum of care meetings; however, some providers reported that this mechanism is not always satisfactory. Providers also reported good working relationships with the local pharmacists, which is particularly important in remote areas where there are fewer permanent health staff. For many people their pharmacists may be the health professional they see most often and most consistently. Overall, service providers reported at baseline that, the service system is reasonably effective in networking, service coordination, cooperation and collaboration, with the following ratings out of 10 provided by the DoGP and the AHS.

Table 114: Assessment provided by Division of General Practice with regard to service coordination.230

Service system area(Partnership)

Division of General Practice(Rating out of 10)

AHS(Rating out of 10)

General practice(Rating out of 10)

Networking 8 7 9Service coordination 6 7 9Cooperation 8 7 9Collaboration 6 6 9

Patient experience Given the limitations of the service system, people generally expressed a level of satisfaction with the quality of services available locally. Unsurprisingly, however, people identified the need to travel away for many treatments as the biggest issue with the patient journey. A reccurring theme in this site was financial hardship and the impact of this on access to health services. Although this was also raised at times in other sites, concerns about the costs associated with travel for treatment, food and medication were a particularly strong theme here. This may be because of the increased need to travel for care, and the premium prices people in remote areas pay for basic items like food, fuel and clothing.

230 Based on a self-assessment questionnaire about effectiveness out of 10 against the domains: 1. networking 2. service coordination 3.cooperation and 4.collaboration.


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PreventionThe key issues identified by community members in relation to prevention were: Smoking and access to health foods are the key concerns about health

lifestyle in this location. People have good awareness of the preventive health services available

through the AHS; very few other services are available.Smoking, unhealthy eating and a lack of exercise were all identified as issues by community members, as was alcohol consumption.

“Smoking is a big problem, drugs and alcohol too. Young people are drinking too much.”“There probably needs to be more education about it [smoking].”

Fruit and vegetables and other healthy food options are readily available, however many community members identified cost as being an issue impacting on access to food. Many community members also reported that people eat a lot of take away and junk food, particularly young families who might not have good meal planning and food preparation skills.

“Groceries are expensive, but you can get everything you need at the supermarket - meat, fruit and vegies.”

Community members had good awareness of services provided through the AHS to assist people to make healthy lifestyle choices, for example men’s and women’s groups. People also identified nurses and AHPs as key informants about lifestyle related chorionic disease risk factors. Community members reported a recent shift in attitudes towards exercise, with many people starting walking groups and other social exercise activities. Some people felt that there were insufficient options for adults and elders to get involved in physical activity. The single biggest issue is the need to travel long distances for many services including diagnosis and treatment of chronic disease. Some people also reported a sense of isolation from the non-Aboriginal and Torres Strait Islander community, which was seen to impact on people’s participation in mainstream community events and activities.

“There are football, soccer games for young people but nothing for seniors.”“There are lots of local community events but we don’t go.”

Diagnosis and treatment The key issues identified by community members in relation to diagnosis and treatment were: Limited range and capacity of primary health care services means that many

people experience long waiting times go without or access a mixture of providers (potentially creating continuity of care issues).


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The need to travel long distances for many services relevant to diagnosis and treatment of chronic disease.

Most community members access primary health care for diagnosis and treatment from a combination of the private GP the AHS and the hospital depending on availability. The AHS and hospital provide free access to GPs. MBS data indicates that in 2009-10 in this site, more services were provided by Medicare Non-recognised GPs than Recognised GPs. This is the only site where this was the case. Community members generally had a very positive view of the services available locally, despite the obvious limitations of the service system (relative to many other places in Australia). For example people reported that they didn’t think waiting times were unreasonable, despite the very limited access they have to GPs. Community members reported that they might go to the hospital and be asked to come back in two or three days (it is assumed that this would only be the case where clinically appropriate).

‘There are more than enough health services here, we have everything we need.’231

‘Transport is only for Elders.’232

This may reflect that people who have lived in remote areas their whole lives and are used to relatively limited services may have different expectations about access to services to people in rural centres and cities. Transport to health services is an issue for some people who live out of town. There is no local public transport at all, so people are reliant on private vehicles and friends and family to get around. The AHS does provide limited patient transport. While people seem to accept that they need to travel to access services, the financial impact, the inconvenience and the disruption to family life were seen as major problems. Community members talked about the importance of making do with the services and the resources available to them, including some use of traditional and alternative medicines.

‘It’s bad going away for treatment, it costs a lot and you miss family and can get really down.’233

‘People with kidney problems have to go to [town over 700 kilometres away], they go on the bus or something they have to stay there. It can get very expensive.’234

‘We have some bush medicines too, some people use gumbi gumbi.’235

People had good awareness of CtG scripts and reported that it had increased access to medications that may otherwise not be purchased when money runs

231 Community member, site six.232 ibid.233 ibid.234 ibid.235 ibid.


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short. Elders and young families were identified as the main beneficiaries of this initiative. The area is no S100 RAAHS in the area, and the AHS was not purchasing medications on behalf of clients before the introduction of CtG scripts due to limited financial resources. Table 115 shows professional attendances and pathology services in 2009-10 for patients found to be ever registered for PIP Indigenous Health Incentive at June 2011.






1,395 558 156 8.9 3.6

Ongoing treatment and supportThe key issue identified by community members in relation to ongoing treatment and support was the need to travel away for ongoing treatment and high turnover of local providers can have a negative impact on continuity of care.The need to travel away for treatment also has an impact on continuity of care, as there is a heavy reliance on providers transferring notes, providing detailed referrals and referral feedback and utilising technology to support shared care arrangements. Some community members expressed some frustration with an apparent lack of communication between providers within health services and between their various providers.

‘They all need to talk more – doctors and nurses, they don’t seem to talk to each other at all.’236

The turnover of doctors locally also impacts on continuity of care, particularly given that some people access doctors from two or even three services (AHS, private GP and hospital). There are relatively few formal support services available in the community; however people did not identify this as a gap or an area of need.

Baseline assessment Table 116 below draws together the information presented above about site six at the final stage. Against conceptual framework domain characteristics, this table provides the rating237 the evaluators gave the site at baseline. Note that these ratings are based on assessment of the information available to the 236 ibid.


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evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.



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Table 116: Assessment against the conceptual framework.Domains Characteristics

Rati

ng

Assessment

System capacity


1 The range and number of services of offer in site six was very limited. Existing services had sufficient facilities (new AHS building greatly enhanced infrastructure).


1 The health workforce itself was limited in size and experienced high turnover.


1 Services were limited, and insufficient to meet community needs locally. Travel was necessary to meet community needs.


1 This was noted as variable given the somewhat limited capacity of organisations and providers within the local service system.


2 Local services had a strong commitment to providing Aboriginal and Torres Strait Islander health care within the service system constraints.


1 Local service were accessible, however travel was necessary to access many secondary and tertiary services. ICDP related programs, such as MSOAP ICD and SS funds, were either not available or limited at baseline.

Services are financially accessible to patients. 1 Local services are generally financially accessible (although limited in terms of scope and capacity). Patients with chronic diseases are often required to travel to access treatment and the costs associated with travel can be prohibitive for some people.

228



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Rati

ng

Assessment

Services target (and are tailored to) multiple patient groups. 2 Local services were available to multiple groups within the community.


2 As appropriate and required in relation to local services.


2 Community members generally indicated that providers were culturally appropriate. The possible exception seems to be some providers at the hospital.


2 As necessary, given that local services were largely considered to be culturally appropriate. Services were receptive to the ICDP, despite limited investment locally.


2 Aboriginal and Torres Strait Islander staff worked at the AHS and DoGP.


2 AHS provided training for non-Aboriginal and Torres Strait Islander staff and for hospital staff.



2 Largely facilitated though personal networks given the size of the service system, although some formal mechanisms were also in place. Largely reported to be effective.


1 Patient-centred care was clearly a priority at both the general practice and AHS. The nurse-led model at the AHS supported good quality care despite the lack of a permanent doctor and high turnover of visiting doctors.

Informal mechanisms or practices that support service coordination and patient-centred planning and care delivery (e.g.,

2 There were strong relationships and coordination at the local level, despite challenges around the transitory nature

229



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Rati

ng

Assessment

referral protocols, service directories, cross-agency awareness training) are in place.

of hospital-based services and the need for patients to travel for many services.


2 Continuum of care meetings was held to support coordination of care across multiple providers, which was necessary given the restraints of individual services.


2 No duplication identified at baseline.

230



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Changes expected to occur as a result of ICDP at baseline At baseline, only one organisation at this site was allocated ICDP funding (the DoGP), however one of these positions (ATSIOW) was actually allocated to provide services outside of the site boundaries (in this example the organisation’s boundaries are much broader than the site boundaries). One general practice and the AHS had signed up for the PIP Indigenous Health Incentive at baseline and were prescribing CtG scripts. Many people in this area, however, reported having difficulty accessing primary health care services through this GP or the AHS because of very limited capacity within both. Thus, the impact of these measures may not be as significant as in other areas. In some cases, people reported having to see the visiting doctors at the hospital, which limits continuity of care and access to CtG scripts. It is understood that the AHS is likely to receive funding for a RTSHLT in the future. Funding through MSOAP-ICD may also become available in the future.

3.6.2 Site six at final At the final stage, the key characteristics of the site remained largely the same, that is: the Aboriginal and Torres Strait Islander community was generally

concentrated in the regional centre and a number of other smaller towns; health services were primarily provided by the regional hospital, one private

GP and the AHS; with an additional health clinic in the process of being established by a new private provider; and

the site was considered to be a district of workforce shortage for general practice.

At baseline, the main ICDP funded mainstream organisation was a DoGP. In November 2011, this DoGP subsequently ceased operating and the Medicare Local, which now covers a broader geographical area, took over the ICDP funding in 2012. Local Medicare Local physical presence commenced in 2012 in temporary accommodation before moving to permanent premises in early 2013.


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ICDP workforce investment and activity at site six

117 below shows the number of ICDP workers allocated to the Medicare Local by final stage.

Table 117: ICDP workforce allocation (FTE) within site six, 2012-13 (various dates).238

Position AHS ML Total Allocation

CC - 1 1ATSIOW 1 2239 3Total 1 3 3

ICDP workforce investment in the Medicare LocalCtG team (ATSIOW and Care Coordinator): The ATSIOW and Care Coordinator in the Medicare Local work closely together as part of the CtG team. The Care Coordinator has been employed for three years and the ATSIOW was employed less than six months ago.The general practice, Medicare Local and hospital each refer patients (with developed care plans) to the Care Coordinator who often provided services to over 60 Aboriginal or Torres Strait Islander patients at any one time. The Care Coordinator also arranges supplementary services to patients, such as transport, specialist and allied health service gap fees, medical aids and equipment, and Webster packs on a needs basis.Due to restrictive lease arrangements, the ATSIOW was not able to drive the car that was hired by the Medicare Local for the purpose of Aboriginal and Torres Strait Islander patient transport. This meant that Care Coordinator was required to provide this service, thus reducing their capacity in other areas of their responsibilities. The ATSIOW instead provided the Care Coordinator with administrative supports and provided patient support on site.MSOAP-ICD: The Medicare Local also facilitates a team of MSOAP-ICD professionals who provide outreach specialist care to Aboriginal and Torres Strait Islander chronic disease patients within the site. These services include cardiac testing, cardiology, dietetics, exercise physiology, respiratory, podiatry and sonography.240

238 Workforce data provided by the former Department of Health and Ageing. Note there are different datasets for each worker type, and each provide point in time snapshots at dates within 2012-13. 239 One of the ATSIOWs provided services to community members outside of the site.240 Based on information sourced online.


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ICDP workforce investment in the Aboriginal health serviceATSIOW: The ATSIOW was employed by the AHS for less than six months. Their responsibilities included: providing transport to Aboriginal and Torres Strait Islander patients; visiting patients in their homes; arranging, discussing and supporting patients with their medical appointments; delivering Webster packs; assisting with CtG scripts; assisting a Men’s Group at the AHS; and generally advocating for their patients. The ATSIOW works closely with other non-ICDP health professionals to ensure that they have knowledge of the various programs and health check events being delivered within the site. Since their engagement, the ATSIOW increased the community’s knowledge of local Aboriginal and Torres Strait Islander health services by talking to individuals, distributing brochures and flyers, and promoting services at local community events.

‘It is important for me to get to know the community, know the elderly more.’241

Impact of the ICDP Each of the changes expected to occur as result of ICDP investment were found to have occurred at the final stage. These expected changes were: Improved access to transport Reduced financial barriers to accessing health care Improved access to specialist and allied health services Increased cultural competency of general practicesIn summary, the key changes as a result of ICDP investment at this site are: system capacity: improved availability of specialist and allied health services; access: improved accessibility to culturally appropriate coordinated care for

CCSS patients, reduced geographical barriers to care, and a significant increase in the number of Health Assessments provided to EverIHI patients; and

service coordination: an improvement in patient-centred coordination and multidisciplinary team care for Aboriginal and Torres Strait Islander patients.


Changes to system capacityIn 2011, the DoGP ceased operations and the Medicare Local was formed taking over the ICDP funded positions; this meant a period of uncertainty for workers and a changeover of staff. This has now stabilised, though there are ongoing challenges in filling all of the ICDP funded positions. It was reported that the

241 Consultation with ATSIOW, site six. 2013.233


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challenges in filling positions related to difficulty in attracting appropriately qualified and experienced staff in the region more broadly.

‘There were difficulties in the change to the Medicare Local and people found it difficult to adapt. There was a lack of systems, policies and procedures, although these are being slowly created. Although the change has created a sound model, it would have been better to have a ‘blank slate’.242

During the evaluation period, the site experienced a significant change in general practice service provision. In 2012, the sole GP announced their intention to retire the following year. This prompted action by the local government resulting in an agreement with a new general practice to establish a new GP clinic within the site in mid-2013. Federal Government changes to service provision structures in rural health care also meant that a Rural Generalist was engaged to provide services at various locations within the site (i.e., the hospital, the AHS and the GP clinic) from 2012. There was also a decrease in doctors within the AHS according to OSR data, see Table 118118 below.The following ICDP investments in site six represent new Aboriginal and Torres Strait Islander-specific health services that align with community need. The CtG program is the first Aboriginal and Torres Strait Islander health

program within the Medicare Local (or the DoGP prior to the transition). The MSOAP-ICD provided additional specialist and allied health care to

Aboriginal and Torres Strait Islander chronic disease patients at no charge. This reduced the need for some patients to travel away from their families and community to receive treatment.

‘The dietician works with the Medicare Local. You tell her what you eat and she will go and work on a diet plan to suit you. She works one on one with people and suggests healthy choices.’243

Care coordination services introduced a consistent contact and support person for Aboriginal and Torres Strait Islander patients with complex chronic conditions, which was noted to enhance individual care between multiple service providers and often different visiting outreach service providers over time.Potentially reflecting the ICDP investment in the region, the range of chronic disease related services offered by the AHS, according to OSR data, expended between baseline and final stages.

242 Consultation with Medicare Local Program Manager, site six. 2013.243 Consultation with Aboriginal and Torres Strait Islander community member, site six. 2013.


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Table 118: Summary of AHS service provision in site six for 2009-10 and 2011-12.244


6.74 0.56 -91.69%


7.16 4.89 -31.70%


60.32% 72.81% 20.71%

Total number of clients 1,851 960 -48.41%Aboriginal or Torres Strait Islander clients as a proportion of total clients

69.15% 56.04% -13.96%

Note: there are a number of limitations with this data, which are explored in the appendices.

Table 119: Summary of chronic disease related services provided by the Indigenous organisation in site six for 2009-10 and 2011-12.245

Service provided by the AHS 2009-10 2011-12Management of diabetes Yes YesManagement of cardiovascular disease No YesManagement of other chronic illness No YesService maintains health registers No YesShared care arrangements for management of chronic disease

No Yes

Chronic disease management groups Yes YesTobacco use treatment/prevention groups No NoNote: there are a number of limitations with this data, which are explored in the appendices.

244 Based on OSR data, provided by the former Department of Health and Ageing. 245 Based on OSR data, provided by the former Department of Health and Ageing.


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Changes to accessibilityThe ICDP has increased both physical and cultural accessibility of services in the region. The Care Coordinator at the Medicare Local was dedicated in ensuring that

Aboriginal and Torres Strait Islander chronic disease patient care was both well-coordinated and culturally appropriate along the whole health service pathway.

‘Quality of life is just as important as quantity of life...Aboriginal people have a culture where family is the core of their lives. It is hard to put into words; it’s something special that is instilled in us from birth. We are raised to care and nurture one another and it is sometimes difficult when we become adults to move far away from our loved ones, even for life saving treatments.’246

‘Looking after cultural needs is a big deal; this is often missed in general practices. This is Primary Health Care principles: access, patient involvement, family involvement, working with the multi-disciplinary team for the best patient outcomes.’247

The CCSS program, Care Coordinator (Medicare Local) and ATSIOW (AHS) all worked towards helping to reduce the geographical barriers experienced by Aboriginal and Torres Strait Islander patients to accessing health care. There seemed to be a low level of awareness, however, of the availability of the transportation services provided by the Care Coordinator and ATSIOW during the Community Forums.

‘We still have to go away and fill in a PTS form. They pay for bus fare but we get reimbursed approximately two to three months later and you don’t get the full amount.’248

‘You think that they could use video conferencing instead. They sent a high-risk pregnant woman to (another town).’249

The number of PIP Indigenous Health Incentive registered patients is illustrated in Table 120120 below. As at 2011, almost three quarters of the Aboriginal and Torres Strait Islander people within site six were EverIHI. This high representation may reflect a high level of patient identification and awareness of ICDP measures within the site.

246 Consultation with Care Coordinator, site six. 2013.247 ibid.248 Consultation with Aboriginal and Torres Strait Islander community member, site six. 2013.249 ibid.


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290


74.85%

There was significant growth in the number of Health Assessments provided to EverIHI patients after 2009-10 and the number of providers of Health Assessments steeply increased in December 2010. That number remained stable thereafter (As noted in the previous chapter, the number of PBS scripts dispensed to EverCtG patients by six month period was similar at sites five and six. At site six (see Table 131131 below) there was an increase in 3,567 scripts between 2007 and 2011. Health Assessments per 100 EverIHI patients increased from 20 in 2009-10 to 71 in 2012 (Table 122).

There were only a handful of follow up allied health services provided and billed through MBS at site six. There was no meaningful change in the numbers of allied health follow-up services and their numbers remained low throughout the period from 2007 to 2012.

Similarly the number of allied health follow-up services per 100 EverIHI patients remained unchanged (Table 123122).There was no notable change in either the numbers of attendances at specialists, in the number of specialist providers (Table 126) or the number of attendances at specialists per 100 EverIHI patients (Table 124124).Numbers of GP attendances underwent some increase after 2009-10 but this occurred entirely within the 2010-11 year. However, the number of GPs providing services to the Aboriginal and Torres Strait Islander community of site six increased steadily from a low of 86 in 2009-10 to a high of 113 in 2012 (Table 127127). The number of GP attendances per 100 EverIHI patients was 903 in 2009-10 and had increased to 978 in 2012 (Table 128128).

250 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra.251 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.252 MBS data supplied by the former Department of Health and Ageing, 2013.253 This is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period. As such, the Patients (EverIHI) values may not always match the numbers in the proceeding tables.


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There was also an acceleration of growth in pathology tests for EverIHI patients at site six, from June 2011 (Table 129129). This was reflected in the pathology tests per 100 EverIHI patients (Table 130130).These findings suggest some change to the patient journey for EverIHI patients at site six, revolving around increased Health Assessments for EverIHI patients. There is no substantial evidence of this leading to increased use of secondary services for EverIHI patients, such as allied health follow up and specialist services. While there is increased use of GP services for this patient group, this increase was a continuation of trends prior to the baseline year.As noted in the previous chapter, the number of PBS scripts dispensed to EverCtG patients by six month period was similar at sites five and six. At site six (see Table 131131 below) there was an increase in 3,567 scripts between 2007 and 2011.

Table 121: Numbers of Aboriginal and Torres Strait Islander Health Assessments, providers of Health Assessments and average Health Assessments per provider254, site six, by six month period, 2007 to 2012.255

Six months ending





Table 122: Number of EverIHI patients, Health Assessments and Health



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Assessments per 100 EverIHI at site six in 2009-10 (baseline period) and calendar year 2012.256

Statistic 2009-10

2012


20 71

Table 123: Number of EverIHI patients, Allied health follow ups, Allied health follow ups per 100 EverIHI and Allied health follow ups per 100 Health Assessments at site six in 2009-10 (baseline period) and calendar year 2012.257

Statistic 2009-10

2012


5 2

Table 124: Number of EverIHI patients, Specialist attendances and Specialist attendances per 100 EverIHI at site six in 2009-10 (baseline period) and calendar year 2012.258

Statistic 2009-10

2012


25 27



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Table 125: Numbers of allied health follow up services259 for EverIHI patients at site six, by six month period, 2007 to 2012.260

Six months ending


June 2007 -December 2007 2June 2008 2December 2008 -June 2009 -December 2009 3June 2010 1December 2010 5June 2011 5December 2011 7June 2012 3December 2012 4

259 MBS subgroup M03—Allied Health Services plus MBS subgroup M11--Allied Health Services For Indigenous Australians Who Have Had A Health Check.260 MBS data supplied by the former Department of Health and Ageing, 2013.


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Table 126: Numbers of specialist attendances, specialist providers and attendances per provider, for EverIHI patients at site six, by six month period, 2007 to 2012.261

Six months ending



Table 127: Numbers of GP attendances, GP providers and attendances per provider, for EverIHI patients at site six, by six month period, 2007 to 2012.262

Six months ending


June 2007 721 80 9.0December 2007 764 92 8.3June 2008 852 97 8.8December 2008 897 98 9.2June 2009 913 97 9.4December 2009 973 86 11.3June 2010 833 86 9.7December 2010 1,030 101 10.2June 2011 1,098 93 11.8December 2011 1,051 110 9.6June 2012 1,057 113 9.4December 2012 1,055 112 9.4

261 ibid.262 ibid.


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Table 128: Number of EverIHI patients, GP attendances and GP attendances per 100 EverIHI at site six in 2009-10 (baseline period) and calendar year 2012.263

Statistic 2009-10

2012



903 978

Table 129: Numbers of pathology services for EverIHI patients at site six, by six month period, 2007 to 2012.264

Six months ending

Pathology services


Table 130: Number of EverIHI patients, Pathology services and Pathology services per 100 EverIHI in 2009-10 (baseline period) and calendar year 2012.265

Statistic 2009-10

2012

EverIHI patients 200 216Pathology services 995 1,42


498 661



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Table 131: Number of PBS scripts dispensed to EverCtG patients by six month period, site six, 2007 to 2012.266

Six months ending

Scripts


Changes to service coordinationAt baseline, the AHS and local general practice reported a positive relationship with each other and the local hospital. The DoGP (which had a very large service area) had limited interactions with the AHS, although both organisations reported that the relationship was positive at baseline. Many Aboriginal and Torres Strait Islander patients accessed multiple services, making it difficult to coordinate care for patients, especially those with chronic disease(s). The AHS and hospital were managing this through a schedule of continuum of care meetings; however, some providers reported that this mechanism was not always satisfactory. The addition of the Care Coordinator represented an improvement in patient-centred coordination and multi-disciplinary team care for Aboriginal and Torres Strait Islander patients within the site. This includes coordinating culturally appropriate care for patients who must receive treatments in locations far away from their community for extended periods of time.

‘The Care Coordinator helps circumvent the ‘GP to hospital and back again revolving door’. They use a holistic approach and address Aboriginal and Torres Strait Islander patients’ health and wellbeing needs.’267

266 Pharmaceutical Benefits Scheme data. Provided to KPMG by the Department of Health, 2013.267 Consultation with Medicare Local CEO, site six. 2013.


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‘I organised accommodation for Nick with a fulltime support person...We also arranged travel and for a family member to travel with him and stay to help with homesickness. I spoke with the social worker and she arranged for Nick to have visits from male Aboriginal Liaison Officers (ALOs). This is an important part of Aboriginal Culture; that men feel more comfortable with Men’s business.’268

The relationship between the new Medicare Local and the AHS was described as ‘challenging’. While there are strong relationships building between the organisations’ frontline workers at the organisation and management level, there has been ongoing debate and conflict over funding apportionment and how the ICDP positions should be translated in practice to best meet local community needs.

Impacts of ICDP on patient experience The yellow boxes reflect ICDP investment and facilitators observed as a result of the ICDP. The most significant improvements to the patient journey at this site can be linked back to improved availability of mainstream culturally appropriate health care coordination and improved access to transportation.The following changes to the patient journey were noted: Increased access to health care services. The ATSIOW and Care Coordinator

improved Aboriginal and Torres Strait Islander access to health care services by providing them with transportation, advocacy and other supports. MSOAP-ICD health professionals provided additional specialist and allied health services to Aboriginal and Torres Strait Islander chronic disease patients within the site.

Increased access to affordable medication, transportation, and medical aides and equipment. Assistance with transportation, specialist and allied health gap fees, medical aids and equipment, and Webster packs were available through the CCSS program within the Medicare Local. Affordable medication was available through CtG scripts, which were provided to Aboriginal and Torres Strait Islander chronic disease patients by the AHS and the general practice.

‘The AHS does an information session about how to access CtG scripts. Some chemists know their clients and can service them without having to show their health care card.’269

Increased availability of patient centred coordinated care. Care coordination provided to Aboriginal and Torres Strait Islander patients by the Care Coordinator represented a new service that was not available to many patients before ICDP funding. The Care Coordinator uses a CDSM approach as this focuses on the social and emotional wellbeing of the patients.

268 Consultation with Care Coordinator, site six. 2013. Note patient details have been changed to de-identify.269 Consultation with Aboriginal and Torres Strait Islander community member, site six. 2013.


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‘My patients come from a culture of storytelling, or ‘yarning’ and [CDSM] allows them to do this.’270

‘I didn’t know that I could get special shoes because I am diabetic. I went to the Medicare Local and they sent me to get some fitted.’271

Ongoing challenges relevant to ICDP Three key barriers were evident at site six at final stage, which are outlined below. Geographical isolation and poor availability of transport. While additional

transport was provided by the Care Coordinator and ATSIOW, this was not adequate to meet a high level of need within the community for this service. By having to provide transportation to clients, the Care Coordinator had less time available to focus on providing care coordination.

Continued gaps in health service provision. Chronic mental health conditions are an issue within the site, particularly amongst young Aboriginal and Torres Strait Islander men. Mental health services to meet the needs of this group are not easily available.

‘It takes a long time to see a mental health worker. I had to bury my nephew; he was only 25 and had mental health issues and was a drug user. The brother is thinking the same way and he doesn’t know where to turn to.’272

Limited improvement in cultural awareness for general practices. While Medicare Local contractors were required to have cultural awareness training, this was not provided within the Medicare Local and it was unknown if new private health care professionals within the site were required to attend such training. In addition, a number of stakeholders reported that the level of cultural awareness within the Medicare Local was very poor, with low levels of cultural appropriateness.

‘The Medicare Local doesn’t understand Aboriginal people. Some of their past practice has been culturally inappropriate and many are dissatisfied with the organisation and the support they provide.’273

270 Consultation with Care Coordinator, site six. 2013.271 Consultation with Aboriginal and Torres Strait Islander community member, site six. 2013.272 ibid.273 Consultation with Care Coordinator, site six. 2013.


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3.6.3 Final assessment Table 132132, Table 133133 and Table 134134 below draw together the information presented above about site six at the final stage. Against conceptual framework domain characteristics, this table provides: the rating the evaluators gave the site at baseline274; the rating the evaluators gave the site at final stage275; the key changes observed; and what these changes appear to be attributable to.Note that these ratings are based on assessment of the information available to the evaluation with regard to the presence and sufficiency of each characteristic. Ratings were applied by the evaluators and were not verified with stakeholders.Figure 11 and Figure 12 below provide a visual representation of the findings within this chapter as at baseline and as at the time of the final evaluation. Each figure is presented as a systems map which details, on a single page, the health services provided within the community, primary, secondary and tertiary sectors within the site. Each patient services map includes the: AHS and mainstream services/supports located within the site; ICDP staff and programs (post-ICDP map only); linkages between services, where these are in place; and identified facilitators and barriers to patient accessibility to these services.



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Table 132: Assessment of change against the conceptual framework - domain 1: system capacity.Characteristics

Base

line

rati

ng

Fina

l ra

ting



1 1 There have been no changes to infrastructure within the site.

Not applicable.


1 1 There was no significant change. There remains an insufficient level of health workforce, particularly GP service provision, and the existing workforce continues to experience a high turnover.

Not applicable.


1 1 There was an increase in the availability of specialist and allied health care within the site.

MSOAP-ICD provided additional cardiac testing, cardiology, dietetics, exercise physiology, respiratory, podiatry and sonography services.


1 2 There may be improvements in practice management within the Medicare Local after the transition from DoGP. Otherwise, there have been no other changes within the site since baseline.

While the clinical information system had not changed in the AHS, the ATSIOW increased usage and reporting practices.


2 2 Local services remain unchanged, in their strong commitment to providing Aboriginal and Torres Strait Islander health care within the continuing service system constraints.

Not applicable.

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Table 133: Assessment of change against the conceptual framework - domain 2: access.Characteristics

Base

line

rati

ng

Fina

l ra

ting



1 1 There have been improvements to the geographic accessibility to patients through improved outreach transport and funding for transport to secondary health care services in regional and city centres. Some new secondary services were made available within the site, reducing the need to travel in some cases.

The ICDP funded ATSIOW (AHS) and Care Coordinator (Medicare Local) provided transport to patients so that they could access health services. The CCSS program also provided funding for transport to eligible patients. The MSOAP-ICD program reduced the need to travel for some patients, although these services were limited.


1 2 The MSOAP-ICD provided additional, local, free specialist and allied health care to patients at no charge which reduced the need for some patients to undertake expensive travel to access services. Assistance with transportation, specialist and allied health gap fees, medical aids and equipment, and Webster packs were al enhanced through the CCSS program, and CtG scripts have reduced financial barriers to accessing medication.

ICDP programs have somewhat reduced financial barriers (CtG scripts, CCSS, MSOAP-ICD).


2 2 There was no change. Local services continued to be available to multiple groups within the community.

Not applicable.

There are protocols or mechanisms in place to support culturally appropriate care such as inclusion of family members in appointments and decision

2 2 There was some change to the availability of culturally appropriate care. This was through an increase in usage of local services, in particular the AHS and CCSS within the Medicare Local.

There was an increased focus on Health Assessments and chronic disease awareness promotion at the AHS and access to appropriate services promoted by the Care coordinator.

248



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Characteristics

Base

line

rati

ng

Fina

l ra

ting


making.Services take steps to ensure a culturally appropriate environment for patients AND/OR…

2 2 Community members continued to report that providers were culturally appropriate.

Not applicable.


2 2 Services were receptive to the ICDP, despite limited local investment. The Medicare Local was supportive of the need to develop a more culturally appropriate health care system within the region.

Not applicable.


2 2 Aboriginal and Torres Strait Islander staff worked within the AHS and the Medicare Local.

The ICDP funded ATSIOWs and Care Coordinator all identified as Aboriginal or Torres Strait Islander.


2 2 AHS continued to provide training for non-Aboriginal and Torres Strait Islander staff and for hospital staff. The Medicare Local was considering engaging in cultural awareness training.

Not applicable.

249



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Table 134 Assessment of change against the conceptual framework-domain 3: service coordination.Characteristics

Base

line

rati

ng

Fina

l ra

ting



2 2 The existing personal networks and formal mechanisms were enhanced through improved levels of communication between the Medicare Local and service providers across all levels of care.

The ICDP funded Care Coordinator created networks with other health service providers. The Medicare Local promoted PIP Indigenous Health Incentive to all practices under its jurisdiction, including those within the site.


1 2 Patient-centred care continued to be a priority at both the AHS and the Medicare Local. There was in improvement in the availability of care coordination since baseline.

The ICDP funded Care Coordinator provided care coordination for many patients within the site. This has improved care planning and delivery of culturally appropriate services.


2 2 There remained strong relationships and coordination at the local service provider level.

Not applicable.

Formal mechanisms or practices that support service coordination and patient-centred planning and care delivery (e.g., dedicated case management resources, availability of brokerage funds, co-location of services, shared information systems and joint planning) are in place.

2 2 The continuum of care meetings have remained in place, however the regularity of these was noted by stakeholders as ‘sporadic’.

Not applicable.

Services within the system are complementary 2 2 There continued to be no identifiable Not applicable.250



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Characteristics

Base

line

rati

ng

Fina

l ra

ting


and there is no duplication. duplication of services.

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Site six (SSE) pre ICDP – patient journey map

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Ongoing access

Ongoing access

Ongoing access Ongoing access

Ongoing access

IHS

Bulk Billing

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Mainstream GP practices

State Health Centre


Long waiting times

State Health Centre

IHS Healthy Lifestyle programs


IHS visiting specialists Cost of

medication when travelling not


Local Pharmacy

State Health Centre

Welfare


Individual motivation and

drive S100 supply arrangements

Support Services


Housing


Dietician

Lack of access to alternatives

Local Pharmacy

Cultural appropriateness

Education

IHS


Lack of follow-up and continuity of

care

Lack of access to program workers

Healthy Lifestyle programs

Employment



Supportive Environment

Racism

Dietician



Lack of culturally appropriate

resources and programs

Referral

No systematic approach for identification

Cost

Ongoing access

Transport

Low cost medications

Cost of medication

Lack of support for individual change*

High staff turnover


ICDP staff/program

Figure 11: Patient service map site six: Baseline. Source: KPMG.

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Site six (SSE) with ICDP – patient journey map

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SupportAccess

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Ongoing access

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Ongoing access

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IHS

Support for individual change*

Bulk Billing



RTSHL

State Health Centre


Long waiting times

State Health Centre

IHS Healthy Lifestyle programs


IHS visiting specialists Cost of

medication when travelling not


Lack of community awareness about

ICDP and full benefits

Lack of clarity about eligibility for CtG Scripts

Local Pharmacy

ATSIOW (C2)

State Health Centre

Welfare


Individual motivation and

drive S100 supply arrangements

CtG registration*Support Services


Housing


Dietician

Lack of access to alternatives

Local Pharmacy

Cultural appropriateness

Education

Increased access to lifestyle modification

programs* IHS


Lack of follow-up and continuity of

care

Lack of access to program workers

Healthy Lifestyle programs

Employment



Supportive Environment

Racism

Dietician



Lack of culturally appropriate

resources and programs

Referral

Lack of community

awareness about ICDP and full

benefitsNo systematic approach for identification

Cost

Ongoing access

Transport

Low cost medications

High staff turnover

Figure 12: Patient service map site six: Final. Source: KPMG.

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4 The baseline patient journey and service system This chapter draws together the information about the six sites at baseline and identifies commonalities and points of difference associated with regionality. This chapter also identifies what ICDP impacts seemed likely based on what was known about ICDP investment and activity at the time. This is necessary because it is not reasonable to expect that the ICDP would address all the gaps, barriers and challenges identified by community members and stakeholders when they reflect on the experience of patients with a chronic disease, or the strengths and limitations of their local service system.

4.1 Overview of the sites at baseline At baseline, the two urban sites276 were typified by the following: System capacity: there were a large number and broad range of services

available and both sites had a large, highly functional AHS. Community members in both sites were accessing both AHS and general practice, in a combination to suit their needs.

Access: Aboriginal and Torres Strait Islander people were dispersed across the location in both sites, and not necessarily living close to any one service. Access to public transport was generally good, although access to private transport was limited for some people. As would be expected, the AHSs were generally considered to be providing culturally competent services. There were enough general practice services to provide choice for Aboriginal and Torres Strait Islander people wishing to access mainstream services, many of which (although not all) were considered by community members to provide culturally appropriate care. Major public hospitals in both sites had implemented programs to improve cultural sensitivity.

Service coordination: patient experiences in both sites reflected the complexity of navigating the health system in urban areas where there is high service system capacity because of the multiplicity of providers and referral options. Further, informal coordination was found to be less common and less effective in urban locations, and this is also likely to be associated with the scale and complexity of the service system compared to regional and remote areas.

At baseline, the three regional locations were typified by the following: System capacity: although there were AHSs and/or other Aboriginal

Community Controlled Organisations (ACCOs) in each of the sites, access to these services was restricted due to limited transport, waiting times and the scope of services provided. Each site had at least one small hospital, but there was often need to travel to the city or larger towns to access key

276 Sites One and Two, which are classified as Major City according to the Australian Standard Geographical Classification (ASGC) remoteness structure.


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services. GP services were generally limited, with only a small number of choices in smaller towns and communities.

Access: the AHSs at all sites were seen to provide culturally competent services; however, the cultural competency of general practices was variable across sites. Each of the hospitals had a program or programs to increase cultural competency of services, such as the employment of Aboriginal Hospital Liaison Officers (AHLOs). This was important given the high access to hospital services by Aboriginal and Torres Strait Islander people in regional areas (as reported by stakeholders), such as for afterhours care, or where the hospital was the only service providing free health care. As in many other places, cost of services and access to transport were considered key barriers, and the requirement to travel long distances between towns for some service types was seen as a significant issue.

Service coordination: The effectiveness of relationships between providers and between the Aboriginal and Torres Strait Islander and mainstream sectors was variable, and was influenced by proximity of services and historical attitudes to sharing information and collaborating.

The following summarises the patient experience and service system at the remote location: System capacity: the site had both an AHS and a small general practice

system. As with most remote locations, the site had a limited number and range of infrastructure, human resources and services available.

Access: the AHS was providing culturally appropriate care. Findings indicate that general practices were largely culturally sensitive also. Community members were required to travel long distances to access many services.

Service coordination: service coordination within the site was reported to be good, with the small number of providers working closely together despite challenges around staff turnover and sharing patients. Coordination of care when patients travel outside of the community to access services was found to be challenging.

4.2 Key statistics Among patients who had ever been registered for PIP Indigenous Health Incentive (referred to as the EverIHI group)277 in urban sites, the total number of Health Assessments was high, but the corresponding proportion was lower than the regional sites and much lower than the remote site. The proportion of EverIHI patients who had received at least one Health Assessment by 2009-10 was: 16.1 per cent in urban sites; 20.4 per cent in regional sites; and 34.0 per cent in the remote site.

277 This is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period.


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The majority (74.6 per cent in urban sites, 76.2 per cent in regional sites and 74.4 per cent in the remote site) of these EverIHI patients had at least one visit to a GP during 2009-10. This was fairly consistent across sites. EverIHI patients in urban sites were twice as likely to see five, or more, different general practitioners than patients in other sites (28.8 per cent in urban sites and 14.9 per cent in regional and remote sites), in 2009-10.Regional sites patients who had ever been registered for the PIP Indigenous Health Incentive were more likely to see only one or two GPs in 2009-10 than were urban patients (37.9 per cent compared with 23.9 per cent), but less likely to do so than patients in the remote site (41.2 per cent).Over half of EverIHI patients in urban sites both attended at least one medical practitioner and were subjected to at least one pathology test in 2009-10 (56.5 per cent), with 5.0 per cent also receiving at least one allied health service for a person with a chronic disease. These proportions were similar to those for regional and remote sites.278

In 2009-10, there was an average of 14 allied health follow-up services delivered for every 100 EverIHI patients in urban sites. This rate was marginally higher than that for regional sites (13 per 100 EverIHI patients) and much higher than the rate for the remote site (two per 100 EverIHI patients).

4.3 Patient experience of gaps, challenges and barriers The discussion below describes the key challenges and barriers faced by at baseline. There were a number of challenges identified that applied across the continuum of care: Demand for more Aboriginal and Torres Strait Islander-specific programs and

resources – community members consulted indicated a strong preference for Aboriginal and Torres Strait Islander specific programs, which they considered more likely to meet their needs. Community members also indicated a strong desire to have access to programs with an individual focus, rather than group based programs. There was also demand for Aboriginal and Torres Strait Islander specific resources.

Demand for Aboriginal and Torres Strait Islander workers, and a perception that the current workforce still could not meet demand. Similarly, community members expressed a strong desire to work with Aboriginal and Torres Strait Islander health workers, but across all sites, there were gaps in this area. In the sites with large AHSs (sites one, two and four), this was less of an issue, but community members in these sites still noted the limited number of Aboriginal and Torres Strait Islander workers in mainstream organisations.

278 Over half of regional EverIHI patients both attended at least one medical practitioner and were subjected to at least one pathology test in 2009 10 (57.4 per cent), with 4.8 per cent also receiving at least one allied health service for a person with a chronic disease. Over half of remote EverIHI patients attended both at least one professional attendance by a medical practitioner and at least one pathology test in 2009 10 (55.8 per cent).


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Cultural appropriateness of general practices. Community members at all sites identified some services that were not considered culturally appropriate, although the extent of this varied. For example in site one most general practices were considered to be culturally appropriate whereas in site three, the majority were not.

4.3.1 PreventionThe common challenges and barriers identified relating to the ‘prevention’ setting were: Unhealthy lifestyle behaviours. At all sites, community members and service

providers provided many examples of common, unhealthy behaviours within the community such as smoking, lack of exercise and poor diet. In all sites, there were examples of people ‘living well’ but this was certainly not all people. Community-level factors, such as social norms and the costs and availability of fresh food, were seen to influence this. The addictive nature of smoking was also considered a main reason for the high smoking rates.

Limited preventive health care access. At all sites community members noted that many people do not access health care for preventive purposes, such as going to the GP for a health check. Rather, they wait until they are sick. This is expanded on under ‘concerns about accessing health care’ below.

4.3.2 Diagnosis and treatmentThe common barriers and challenges identified for the ‘diagnosis and treatment’ setting were: Concerns about accessing health care. Many examples were provided of

community members not accessing health care until crisis point due to fears of a health problem being identified or lack of understanding of the health care system and where to go to access services.

Difficulties associated with appointments. At sites one, two, four and five community members described long waiting times for primary health care appointments, this was primarily relevant to the AHS sector.

The upfront costs associated with accessing health care. Such as transport and accommodation, medicines, primary health care and initial access to specialists and AHPs. This was identified as a significant barrier at all sites.

4.3.3 Ongoing treatment and supportThe common barriers and challenges identified for the ‘ongoing treatment and support’ setting were: costs – the ongoing costs associated with chronic disease management such

as for medicines, attending regular appointments, transport and accommodation;


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motivation and support to continue with treatment – linked to factors such as the costs of ongoing health care access, competing priorities and mobility. This was identified as a barrier across the sites; and

concerns about accessing health care – the major concern reported by community members (at sites one, two, three, four and six) was not wanting to access services at the hospital for fear of dying in hospital.

4.4 Changes expected to occur as a result of ICDP At baseline, it was possible to hypothesise that a number of changes would occur as a result of the implementation of the ICDP. This section outlines these expected changes, and draws on what was known about ICDP investment at baseline, as well as expectations articulated by community members and stakeholders.

4.4.1 Changes expected to occur at all sitesIn all sites, the ICDP was expected to increase the number of staff working in Aboriginal and Torres Strait Islander health. The recruitment of staff through the ICDP, particularly the significant recruitment to the mainstream sector, was expected to change the profile of the health system. This was expected to occur both by increasing the number of Aboriginal and Torres Strait Islander people employed within the health care system, and the overall number of all staff dedicated to addressing Aboriginal and Torres Strait Islander health. Further, this was expected to lead to the organisations providing a greater range of services and increasing their capacity to cater to community needs. In the mainstream sector, this was expected to lead to more culturally appropriate service delivery, and Aboriginal and Torres Strait Islander people being more willing to access general practices. The information collected from patient journey mapping and service mapping at the site level suggested that the ICDP would have a core role, across all locations, in addressing financial barriers to accessing health care identified by community members, particularly through CtG scripts and Supplementary Service (SS) funds, and also Urban Specialist Outreach Assistance Program (USOAP) and Medical Specialist Outreach Assistance Program Indigenous Chronic Disease (MSOAP-ICD). For example, across all locations, patients discussed the costs associated with accessing specialist and allied health services outside of free clinics as a barrier. This included the cost of the appointment itself and associated transport and accommodation costs. At baseline, some of the sites planned to implement USOAP (site two and site one) or MSOAP-ICD (site six). Other sites had CCSS funding and were planning to utilise the SS funds to pay for appointments and travel for patients (sites one, three, four and five). Whether intentionally or coincidentally, the allocation of funding across the sites resulted in those without USOAP or MSOAP-ICD funding having access to CCSS;


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thus the ICDP was considered likely to have some impact on addressing issues around accessing specialist and allied health care in all locations. Across all of the six sites, it was considered likely that CtG scripts would have a significant positive impact on access to pharmaceuticals, which is important given that at all sites, patients identified the costs of medicines as a barrier. Only one of the AHSs in the six sites had previously provided free pharmaceuticals to regular patients, and none of the AHSs were participating in pharmaceutical schemes such as S100 RAAHS and Quality Use of Medicines Maximised in Aboriginal and Torres Strait Islander Peoples Program (QUMAX).

4.4.2 Changes expected to occur in a variable wayThere was variation across sites regarding whether the ICDP will add new programs and services to the region, or whether existing programs and services would be built upon. Both the introduction of new programs and services, and the enhancement of existing services have the potential to lead to positive impacts, however the exact nature of the impact may differ. Related to this, the use, and therefore the expected impact, of some of the more flexible ICDP measures varied across sites. One example of this is the CCSS measure. In some locations, existing transport subsidy schemes seem to be more easily accessible (while this could reflect varying jurisdictional requirements it could also reflect the competency of staff to facilitate access) so it is less likely that Supplementary Services funds would be used for transport and less likely that improved access to transport would be identified as a major impact.The level of receptivity to ICDP was likely to be influenced by the capacity, as well as the culture, within organisations in relation to the importance placed upon Aboriginal and Torres Strait Islander health. While the AHSs in the sites demonstrated a deep commitment to improving Aboriginal and Torres Strait Islander health (as would be expected) there was variation between mainstream organisations across the sites. This variation is likely to influence the uptake, prioritisation and impact of the ICDP across sites. The uptake of the PIP Indigenous Health Incentive and the PBS Co-payment differed across sites at baseline. Importantly, there was a lot of variation in the number of eligible practices, with some sites having relatively few accredited practices. In locations where primary health care services struggle to meet existing demand (such as in site six where there is very limited access to GPs) it less likely that patients will have access to or enjoy the full benefit of PIP Indigenous Health Incentive and the PBS Co-payment. These factors indicate that the impact of PIP Indigenous Health Incentive and the PBS Co-payment is likely to vary across sites. The number and service capacity of primary health care organisations varied across the sites. In the remote and outer regional sites, there were fewer GPs/AHSs and those in place struggled to meet demand. In such locations, the PIP Indigenous Health Incentive and PBS co-payment measures may have a lesser impact as the services may not be able to meet patient demand.


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The availability of specialist and allied health services across the sites varied. For example, sites with major hospitals and/or large and highly functional AHS generally have some access to affordable specialist or multi-disciplinary clinics, however in other locations access to these providers is very limited and measures such as MSOAP-ICD and CCSS would be expected to have a greater and more immediate impact. The allocation of ICDP investment may influence access and therefore the strength and timing of any impacts for patients. In four of the six sites, some ICDP activity was in place within a key AHS and within mainstream organisations. In the other two sites, ICDP investment was only being allocated through DoGPs at baseline. In the sites with investment in both the AHS and mainstream sector, the ICDP is likely to reach a broader range of target patients. This is especially true where ICDP staff within the DoGPs may have to work harder to build relationships with community members and local health care providers to facilitate referrals than workers in AHSs with a well-established client base. Finally, the accessibility of ICDP services varied across the sites, and this was considered likely to affect how well utilised the ICDP programs and services will be by patients. In urban sites, geographical accessibility appeared to be less of an issue, as public transport was generally accessible and transport services provided by organisations did not have to cover large distances. In the regional and remote sites, geographical accessibility was more difficult. All of the regional and remote sites had been allocated at least one Aboriginal and Torres Strait Islander Outreach Worker (ATSIOW) who was providing or planned to provide some level of outreach services, but the ATSIOWs who had already commenced service delivery reported difficulties in meeting demand across the region. It was considered likely that the extent to which the ICDP will support increased collaboration within the service system could vary across sites. The service mapping showed that the existing level of collaboration differed; in some locations (e.g., sites three and four) organisations with ICDP funding were not interacting at all whereas, in other locations, there was good engagement between general practices and ICDP funded organisations (e.g., sites one and two).


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5 Final Patient journey mapping and service mapping summaryThis section summarises the final stage patient journey mapping and service mapping. It uses information collected from the six sites at baseline and at final stage to consider: the common and variable changes that have resulted from the ICDP based on

any observed differences from baseline, with the latter including differences reference by remoteness;

the impact of specific measures on patients, and the service system; ongoing challenges observed across sites; a discussion of the likelihood that findings would be consistent with findings

at other selected Sentinel Sites referred to as follows:- Sites A and B are urban;- Sites C and D are regional;- Sites E and F are remote; and

a summary of contextual influences.

5.1 Changes as a result of the ICDP from baseline to finalAs described in the previous chapter, a number of impacts, or changes, were expected to occur as a result of the ICDP. Some impacts were expected to be occurring at all sites, and others were expected at some sites but not others. This section compares the impacts observed at the final stage to those expected at baseline, and discusses additional changes which were not necessarily predicted at baseline.All of the changes expected to occur at all sites were observed. These changes included enhancement of the capacity of the system through increased workforce and organisational capacity, and improved access to health care through provision of support and reduction in financial barriers: Increase in number of staff working in Aboriginal and Torres Strait Islander

health. The ICDP led to between three (site six) and 12.25 (site one) additional Full time equivalent (FTE) staff in each site.

Organisations providing a greater range of services. All of the main ICDP funded organisations consulted had expanded the range of services provided – this included preventive health and promotion programs, transport support, support for GP practices, care coordination and/or secondary clinical service provision.

Increased organisational capacity to cater to community need. Increased organisational capacity was observed within both ICDP funded organisations


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and other organisations that were engaged with the ICDP. ICDP investment within funded organisations addressed many previous barriers to community needs being met, for example, through provision of transport or new programs to support smoking cessation. The changes within other services, such as GPs, largely related to improved cultural safety from the community’s perspective (e.g., treating patients appropriately, collecting Aboriginal and Torres Strait Islander identification information, bulk billing Aboriginal and Torres Strait Islander patients). ICDP staff (IHPOs, ATSIOWs) had a core role in supporting changes in cultural responsiveness within practices. In particular, the IHPO role supported an increased focus on Aboriginal and Torres Strait Islander identification across a number of sites. Cultural responsiveness remained an issue; there were still some services in all sites providing what was deemed by patients to be culturally inappropriate care.

Reduced financial barriers to accessing health care. The PBS Co-payment (CtG scripts) reduced financial barriers to medicines at all sites. At each of the sites, financial barriers to specialists and/or allied health services were reduced through CCSS and/or USOAP and MSOAP-ICD.

Increased access to specialist and allied health services. This was reported across all sites, as a result of the CCSS and/or USOAP and MSOAP-ICD programs. Where only CCSS was in place, access is necessarily restricted to the case load which can be managed by the care Coordinator(s). The sometimes high proportion of ‘no-shows’ to SOAP clinics constrained the impact of these measures. Across all sites, ATSIOWs supported patients to access health care across the primary and secondary settings, mostly through provision of transport.

Increased access to pharmaceuticals. Increased access to pharmaceuticals was reported at all sites, and attributed to the PBS Co-payment measure including in the remote site six where the AHS was PIP Indigenous Health Incentive registered and S100 was not in place.

Increased access to primary health care. Increased access to primary and preventive health care was reported at all sites, and resulted from one or a combination of the following ICDP initiatives: RTSHLTs (increased access to preventive health information and support), PIP Indigenous Health Incentive, IHPOs (increased cultural competency of practices); ATSIOWs and CCSS (building awareness of services, assisting patients to navigate the system, coordinating care, encouraging access to health care); and CtG scripts (people accessing GPs for CtG scripts). Staff turnover in some sites lessened the impact of these measures.

A number changes were observed as all sites that were not explicitly predicted at baseline: An increase in the number of Health Assessments across the sites. Increases in the number of providers of Health Assessments, and Health

Assessments per provider across most sites, this is described further in section 5.2.


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An increase in the number of general practices offering Aboriginal and Torres Strait Islander health programs. In each of the sites, mainstream providers and organisations were providing Aboriginal and Torres Strait Islander-specific programs, or services to Aboriginal and Torres Strait Islander people (including MBS, PIP Indigenous Health Incentive and PBS Co-payment measure services) at final stage, where this was not the case at baseline.

Comparison with other sites There is consistency between the changes observed at the selected Sentinel Sites and the evaluation sites across most of the expected change areas; thus, the findings from the evaluation are likely to be consistent with findings at other comparable locations. Enhancement of workforce and organisational capacity, reduced financial barriers and increased access were observed across all evaluation sites and Sentinel Sites, albeit some sites experienced a greater level of change than others.The impact of the CCSS and SOAP measures in reducing financial barriers and increasing access to secondary services was identified as one area where the findings from the Sentinel Sites differed to the evaluation sites. These measures were found to have had less of an impact at the Sentinel Sites simply because of a lower level of investment in Sentinel Sites compared to the evaluation sites. The following discusses those changes expected to occur in a variable way, and highlights that there was variability in the uptake of and level of receptivity to different parts of the ICDP depending on community needs, expectations and the value placed by community on certain types of supports. Where patients accessed ICDP measures and the relationships between these organisations also led to variation of impacts across sites. The perceived need for ICDP investment (based on existing service system

capacity at the sites). The perceived need for and value of ICDP services varied across sites. There were some common needs identified by patients, but there was greater need for the following in some sites:- access to secondary services – sites three, four, five and six;- increased cultural awareness of mainstream providers – sites two, three,

and five;- community member knowledge of available supports – sites one, and two;

and- the need for care coordination was less at site one where a state-funded

care coordination program was in place.There was greater need for knowledge of how to access supports in urban areas, where more services were available. Cultural awareness tended to be higher amongst mainstream providers.

Uptake of PIP Indigenous Health Incentive and thus participation in the use of CtG scripts. The number of patients who were EverIHI as a proportion of the


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estimated Aboriginal and Torres Strait Islander population with a chronic disease, varied across sites, from 19 per cent in site five, to 100 per cent in site four and .Although there was consistent high growth in PBS scripts dispensed to EverCtG patients leading up to June 2010 and substantial growth between 2010 and 2012, total numbers and rates of growth varied across the sites.There were more EverIHI patients (as a proportion of the estimated Aboriginal and Torres Strait Islander population with chronic disease) in regional and remote areas than urban areas consistent with baseline. Site five was the exception with the lowest proportion. Utilisation of CtG scripts was higher in urban areas overall, probably as a function of the larger population.

Organisational receptivity to the ICDP. Receptivity varied within sites (e.g., between towns and between organisations), rather than between sites. Receptivity appeared to be a function of an existing commitment to Aboriginal and Torres Strait Islander health within general practices, and the capacity of organisations (particularly AHSs and GPs) to undertake the required changes, such as the recruitment of workers and the implementation of new systems for recall and reminders.

Where ICDP measures are primarily accessed (AHSs, MLs etc.). Across the sites, ICDP programs and services were accessed from a range of organisations – both mainstream and Aboriginal and Torres Strait Islander-focused. The variability observed was slightly different to what was predicted. Rather than there being a primary location from which the ICDP was accessed, at final stage, different components of the ICDP were being accessed from different locations and different subgroups of patients were accessing the ICDP from different services. This variability was a function of:- what ICDP supports patients required to meet their needs;- their location – patients tended to access the services and supports in

close proximity to them; and - their existing patterns of access, so for a patient who usually accesses an

AHS, they would access the ICDP services available through the AHS. In some sites (sites one, two, five and six) patients reported accessing the ICDP across both AHS and mainstream organisation whereas, while other patients primarily accessed services from one organisation (sites three and four). It was generally found to be true that staff within mainstream organisations had to invest more effort in establishing a community rapport and client base than staff located within AHSs.

Extent of collaboration between ICDP funded services. All of the sites saw some improvement in collaboration between the AHS and mainstream sectors, although this varied and influenced by regional contexts, such as the existing relationships between providers and their geographical proximity. The transition to Medicare Locals enhanced collaboration in some sites (e.g.,


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site one) and limited it in others (e.g., site four). In some sites, the transition had little impact in this area (sites three, two and six).

How well the ICDP will be utilised by patients (based on accessibility). Utilisation of the ICDP varied across sites, and this appeared to be impacted by a range of factors which also varied across sites:- Geographical accessibility. This was a limiting factor particularly in sites

where ICDP investment was allocated to a number of different organisations delivering services from a range of locations (as was the case in sites four, five and six). In site two, accessibility was reported to be limited because the population was dispersed rather than because the services were delivered from a number of different locations.

- Community engagement with health care and motivation to engage with health care .This varied across and within sites with no distinct pattern.

- Measure models and associated constraints. In some sites, the models adopted facilitated a greater reach (e.g., the CtG team models in sites one and three).

- Community needs. As noted above, the perceived need for and value of ICDP services varied across sites, which dictated which services were accessed by community.

Accessibility was more difficult in regional and remote sites where programs and services are expected to cover large geographical areas and where patients may have to travel long distances to access services. There were no distinct regional variations in the other factors influencing ICDP utilisation.

A number of variable changes were observed that were not explicitly predicted at baseline: Alleviation of patient concerns about accessing health care. Patients at sites

one, three and four noted that working with ATSIOWs and Care Coordinators gave them confidence about engaging with health care.

Increased focus on and improvements in data collection and reporting. This was observed at sites two, four and six.

Comparison with other sitesConsistency between the evaluation sites and the selected Sentinel Sites is evident for some of the variable changes observed and not others. Where there is inconsistency, this is likely to be due to differing baseline levels of receptivity and collaboration between sites (essentially, influenced by differing community level and service system factors) rather than reflecting differences between the evaluation and Sentinel Sites overall. Thus, the evaluation findings are likely to be consistent with findings at other comparable locations. Areas where consistency was observed include:


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the perceived value of ICDP investment, which varied depending on community needs and characteristics and also, what services were already being provided at sites when the ICDP was rolled out;

the uptake of the PIP Indigenous Health Incentive and PBS Co-payment measures, which varied across sites influenced by factors such as practice receptiveness and community need for pharmaceuticals;

where the ICDP is accessed from, which parts of the ICDP are accessed and by whom, which varied between sites; and

how well utilised the ICDP is, which varied based on a range of factors. Areas where there was inconsistency between the evaluation sites and Sentinel Sites were: the level of readiness for the ICDP. While this varied within rather than

between the evaluation sites, there were more distinct variations between the Sentinel Sites; for example the community was less ready to receive the measures in site F compared to other Sentinel Sites; and

the level of collaboration between ICDP funded services – there was some improvement at all the evaluation sites in this area between baseline and final stages, although the level of collaboration at final stage varied between sites. In contrast, some of the Sentinel Sites did not see any improvement in this area.

5.2 Impact of specific measuresThe sections above discuss the changes expected and observed at the whole of package level, resulting from the collective impact of a number of measures. The following discussion provides an overview of how the specific measures impacted on the patient journey across the sites. Not all measures were implemented in all locations and the site specific chapters (refer to chapter 3) provide detailed information about local investment. This section provides a snapshot of each measure across the sites.

5.2.1 National Action to Reduce Indigenous Smoking Rates (A1) and Helping Indigenous Australians Reduce Their Risk of Chronic Disease (A2)The RTSHLT measure provided patients across a number of sites (one, two, three and four) with additional Aboriginal and Torres Strait Islander-specific healthy lifestyle programs.RTSHLT workers assisted patients in some sites (sites one, and four) to make healthy lifestyle changes, including going to the gym, ‘getting out more’ and eating better. This was restricted to patients who had worked with team members in group-based programs.


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Through the RTSHLT (in sites one and four) some patients accessed Nicotine replacement therapy (NRT) and/or a Health Assessment (i.e., through RTSHLT workers linking patients with GPs).

5.2.2 Local Indigenous Community Campaigns to Promote Better Health (A3)There was limited awareness of this measure within the patient journey mapping and service mapping sites. There was some awareness at site four), where the local community campaign (LCC) had engaged patients in a community garden project which had taught participants about healthy eating. LCCs were present in or close to all sites except site five.

5.2.3 Subsidising PBS Medicine Co-payments (B1)At all sites, community members and service providers reported that this measure had a significant impact on the patient journey by supporting access to pharmaceuticals: many patients reported that they now access medicines more frequently; and some reported that they are more comfortable going to the GP because they know that they can get the medicines that have been prescribed to them. Small numbers of patients at most sites also reported that the increased access to medicines has helped them get their chronic disease under control. Analysis of PBS data for the six sites shows consistently high growth in PBS scripts dispensed to EverCtG279 patients leading up to June 2010. EverCtG people were dispensed more medicines under PBS arrangements, part of which is attributable to the ICDP and part due to other factors such as the introduction of new medicines to the PBS (see Volume 1 of the Final Report for a detailed discussion of this issue). Further, the fact that some medicines were below PBS co-payment threshold280 and so did not appear in PBS data before CtG commenced. The growth in PBS scripts dispensed to NeverCtG patients was less than to EverCtG patients leading up to June 2010 and grew more slowly or afterwards, at each site. This suggests that use of PBS medicines by EverCtG patients increased over and above the impact of these other factors, after June 2010, and at each site. Note that due to seasonality effects, the data has been analysed for annual time periods.

279 All Aboriginal and Torres Strait Islander people who have ever been dispensed one CtG script at the time data was extracted.280 The PBS has two safety net thresholds that refers to the total applicable co-payments that when reached by an individual and their family, they may apply for a safety net card that entitles them to further subsidy. Refer to the Safety Net Scheme explanatory notes <http://www.pbs.gov.au/info/healthpro/explanatory-notes/section1/Section_1_5_Explanatory_Notes>.


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http://www.pbs.gov.au/info/healthpro/explanatory-notes/section1/Section_1_5_Explanatory_Notes


June 2014

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Site one (MC) Site two (MC) Site three (IR)Site four (OR) Site five (OR) Site six (VR)

Figure 13: Trend in number of PBS scripts dispensed to EverCtG patients, by 12 month period and site, January 2007 to December 2012 (2007 = 100).281

Figure 13 above282 shows the trends in annual growth of PBS scripts for EverCtG patients at the six sites, before and after the commencement of the PBS Co-payment measure in July 2010. The average annual growth in dispensed scripts ranged from eight per cent to 20 per cent at each site, from January 2007 to June 2010. By comparison, dispensed scripts to NeverCtG patients increased between one per cent and six per cent per annum over the same period, across the sites. The EverCtG growth rate increased substantially after June 2010 around the time the PBS Co-payment measure was implemented for all sites except site two and site four. At site two where average annual growth fell from 13 per cent to 8 per cent and at site four growth remained stable at 18 per cent per annum. Site two 281 Pharmaceutical Benefits Scheme data. Provided to KPMG by the Department of Health, 2013.282 The trends are presented in terms of an index of growth, relative to a value of 100 for the 12 month period from July 2009 to June 2010. This period was chosen as the base period for the index because it was the 12 month period immediately preceding the start of the PBS Co-payment measure. This method is consistent with other, commonly used indexation methods. For example, the Consumer Price Index, the Socio-Economic Indexes for Areas (SEIFAs) developed by the ABS and the Accessibility/Remoteness Index of Australia (ARIA).


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also experienced an atypical trend for MBS utilisation, which is discussed below). For the other four sites, average annual growth in EverCtG scripts for the period from July 2010 to December 2012 ranged from 14 per cent to 25 per cent. By comparison, the trend in dispensed scripts to NeverCtG patients ranged between a two per cent decrease and a three per cent increase per annum over the same period, across the sites.The trends in number of EverCtG patients dispensed at least one PBS script are shown in Figure 14 below. This number was increasing steadily leading up to the start of the PBS Co-payment measure, at a rate between four per cent and 16 per cent per annum at each site. The corresponding range for NeverCtG patients was between zero and four per cent. From July 2010 to December 2012, the rate of annual growth in EverCtG patients dispensed a script accelerated substantially, to between 14 per cent and 31 per cent per annum. In contrast, the trends in number of NeverCtG patients dispensed a PBS script remained essentially stable, at between a two per cent decrease and a two per cent increase per annum.

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Figure 14: Trend in number of EverCtG patients dispensed a PBS script, by 12 month period and site, January 2007 to December 2012 (2007 = 100).283

The trends in number of scripts per EverCtG patient dispensed at least one PBS script are shown in Figure 15 below. This number was increasing steadily leading up to the start of the PBS Co-payment measure, at a rate between three per cent and five cent per annum at each site. The corresponding range for NeverCtG patients was between one and two per cent. From July 2010 to December 2012, the trend for average scripts per EverCtG patient reversed, with average annual decreases between four per cent and six per cent per annum. In contrast, the trends for average scripts per NeverCtG patient remained essentially stable, at between zero and a two per cent increase per annum.

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Figure 15: Trend in number of PBS scripts per EverCtG patient dispensed a PBS script, by 12 month period and site, January 2007 to December 2012 (2007 = 100).284

283 ibid.284 ibid.


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June 2014

When Anatomical Therapeutic Chemical (ATC) classes are considered, specific patterns are observed relevant to the impact of the PBS Co-payment measure on the patient journey as follows.Numbers of diabetes scripts dispensed to EverCtG patients were growing at each site in the period leading up to the start of the PBS Co-payment measure (Figure 16). Growth continued after the start of the measure in July 2010 but at somewhat lower rates for three sites (sites one, two and four), at moderately higher rates for two sites (sites three and six) and at a substantially higher rate for site five. In spite of this variation in trend changes across sites, comparison with the patterns for diabetes scripts dispensed to NeverCtG patients showed higher than expected growth for EverCtG patients between July 2010 and December 2012, for all but one site. The exception was site one, where both EverCtG and NeverCtG trends were for reduced growth after June 2010 with the greater reduction being for EverCtG.

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Figure 16: Trend in number of PBS Drugs Used in Diabetes scripts dispensed to EverCtG patients, by 12 month period and site, January 2007 to December 2012 (2007 = 100).285

285 ibid.271


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The trends in number of EverCtG patients dispensed at least one PBS script for drugs used in diabetes are shown in Figure 17 below. This number was increasing in the period from January 2007 to June 2010, at a rate between seven per cent and 18 per cent per annum at each site. The corresponding range for NeverCtG patients was between three per cent and seven per cent. From July 2010 to December 2012, the rate of annual growth in EverCtG patients dispensed a diabetes script increased to between 10 per cent and 34 per cent per annum. In contrast, the trends in number of NeverCtG patients dispensed a PBS script reduced at all but one site and increased moderately there, resulting in average growth between one per cent and seven per cent per annum.

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Figure 17: Trend in number of EverCtG patients dispensed a PBS Drugs Used in Diabetes PBS script, by 12 month period and site, January 2007 to December 2012 (2007 = 100).286

The trends in number of diabetes scripts per EverCtG patient dispensed at least one diabetes script are shown in Figure 15 below. This number was increasing for three sites, leading up to the start of the PBS Co-payment measure (site 1 at 3.6 per cent per annum, site two at 0.7 per cent, site five at 1.4 per cent). At the other three sites it was decreasing (site three at 1.2 per cent per annum, site 286 ibid.


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four at 2.6 per cent, site six at 0.5 per cent). For NeverCtG patients all sites were experiencing decreasing trends between one per cent and three per cent per annum. From July 2010 to December 2012, the trend for average diabetes scripts per EverCtG patient was decreasing for all sites and at a greater rate than previously for the two of the three sites that were already decreasing. At site four, the annual average decrease reduced from 2.6 per cent per annum before July 2010 to 1.0 per cent per annum thereafter. In contrast, the trends for average scripts per NeverCtG patient remained essentially stable, at between zero and a three per cent decrease per annum.

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Figure 18: Trend in number of PBS Drugs Used in Diabetes scripts per EverCtG patient dispensed a PBS Drugs Used in Diabetes script, by 12 month period and site, January 2007 to December 2012 (2007 = 100).287

Overall, for other ATC classes, there was generally a trend of growth in the number of scripts dispensed to EverCtG patients between 2007 and 2011, with steady growth leading up to 2010 and then escalated growth after June 2010 coinciding with the start of the PBS Co-payment measure.Overall, the above trends suggest that EverCtG patients were more likely to be dispensed PBS medicines after the start of the PBS Co-payment measure in July 287 ibid.


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2010. This increased likelihood appears to be related to the ICDP, over and above other factors. In saying this, the average number of scripts generally fell after July 2010. Together with the very large increases in numbers of EverCtG patients receiving scripts, this suggests that some of the increase in patient numbers is due to dispensing of PBS medicines to ordinary EverCtG patients at prices below the PBS threshold. It is unlikely this effect will account for all of the observed increase in dispensing for this group.

5.2.4 Higher Utilisation for MBS and PBS (B2)At all sites, there was an increase in the total number of MBS services288 provided for EverIHI patients289 (see Figure 21 below). The remote site (site six) started with the lowest MBS utilisation, but saw the largest level of growth between baseline and final stages.Annual average growth rates prior to July 2010 ranged from two per cent to 13 per cent. After July 2010 these annual average growth rates fell substantially at sites two and three and fell slightly at sites five and six. The two sites where growth increased were sites one and four.In comparison, from January 2007 to July 2010 annual average growth in MBS services for all Australians was six per cent, which was higher than the corresponding rate for sites one, three and four but lower than the other sites. For July 2010 to December 2012, the Australian rate fell to four per cent, placing it above sites two and three in this period, and below the other sites.

288 All MBS services.289 Note, site level MBS data was available for EverIHI patients only. EverIHI patients are all Aboriginal and Torres Strait Islander people who have ever been registered for the PIP Indigenous Health Incentive at the time data was extracted. This includes people who registered once but may not have re-registered.


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-2468

101214161820

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Figure 19: MBS services provided to EverIHI patients, by six month period and site, 2007 to 2012.290

The trends for the number of EverIHI patients who received at least one MBS service were essentially flat throughout the period from January 2007 to December 2010, at all but two sites. Site six showed meaningful growth throughout this period, with growth being larger after July 2010 than before then. Site four showed slow growth throughout the period, with similar growth rates before and after July 2010.

290 MBS data supplied by the former Department of Health and Ageing, 2013.275


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As a result of these trends, there was variable growth in the average number of MBS services per EverIHI patient, before and after Jul 2010. Before July 2010, this number grew at between one per cent and 11 per cent per annum and after that date it grew at between three and 11 percent. This growth rate increased between these two periods at sites two, three and six, and it decreased at sites one, four and five.

291 ibid.276


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June 2014

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Figure 21: MBS services per EverIHI patient to receive at least one MBS service, by six month period and site, 2007 to 2012.292

Table 135 summarises the trends in different types of MBS services before and after the baseline year of 2009-10, by site. Key points are: site one experienced increased growth in professional attendances and in

diagnostic procedures and investigations, with decreased growth for miscellaneous services and pathology services;

site two experienced increased growth in allied health services from a low base, with substantially reduced or negative growth in most other services;

site three experienced increased growth off a low base for miscellaneous services and, to some extent for diagnostic procedures and investigations, with a decreased trend for pathology services;

site four experienced substantially increased growth in professional attendances and decreased growth in specialist attendances;

site five experienced a small increase in growth for pathology services and increased growth in diagnostic procedures and investigations from a low

292 ibid.277


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June 2014

base, as well as exacerbation of the reduction in specialist attendances, but from a low base;

site six experienced increased growth in most services, albeit from low bases for several services, with decreased growth for professional attendances.

Table 135: Changes in different types of MBS services before, during and after the baseline year of 2009-10, by site.293 Site Service type 2007 2009-

102012 Average

annual growth to June 2010

Average annual growth after June 2010

Site one (RA1)

Diagnostic Imaging 329 423 542 10.6% 10.4%Diagnostic Procedures And Investigations

434 496 667 5.5% 12.6%

Miscellaneous 174 562 997 59.8% 25.8%Pathology 8,215 9,784 11,22

27.2% 5.6%

Professional Attendances

17,749

19,409

22,722

3.6% 6.5%

Specialist attendances

478 571 656 7.4% 5.7%

Allied health services

93 213 542 39.3% 45.3%

Site two (RA1)

Diagnostic Imaging 53 93 85 25.2% -3.5%Diagnostic Procedures And Investigations

55 77 71 14.4% -3.2%

Miscellaneous 37 211 237 100.6% 4.8%Pathology 1,896 2,420 2,723 10.3% 4.8%Professional Attendances

4,580 5,421 5,420 7.0% -


41 56 56 13.3% -


20 38 125 29.3% 61.0%

Site three (RA2)

Diagnostic Imaging 44 60 60 13.2% -Diagnostic Procedures And Investigations

110 116 127 2.1% 3.7%

293 ibid.278


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Site Service type 2007 2009-10

2012 Average annual growth to June 2010



3,628 3,755 3,912 1.4% 1.7%


86 88 55 0.9% -17.1%


13 22 33 23.4% 17.6%

Site four (RA3)


98 135 183 13.7% 12.9%


4,675 4,634 6,733 -0.4% 16.1%


195 251 284 10.6% 5.1%


21 79 287 69.9% 67.5%

Site five (RA3)


25 33 64 11.7% 30.3%

Miscellaneous 38 92 170 42.4% 27.8%Pathology 904 1,097 1,403 8.0% 10.3%Professional Attendances

1,765 2,287 2,852 10.9% 9.2%


115 111 101 -1.4% -3.7%


3 31 76 154.5% 43.1%

Site six (RA5)

Diagnostic Imaging 17 13 63 -10.2% 88.0%Diagnostic Procedures And Investigations

28 35 96 9.3% 49.7%


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Site Service type 2007 2009-10

2012 Average annual growth to June 2010


Miscellaneous 2 11 98 97.8% 139.8%Pathology 735 995 1,427 12.9% 15.5%Professional Attendances

1,706 2,290 2,732 12.5% 7.3%


48 49 58 0.8% 7.0%


2 4 7 32.0% 25.1%

Access to Health Assessments grew between baseline and final stages, albeit at different rates. Table 136 below shows Health Assessments by six month period and site. The standout inconsistencies were between site one and two which are both in major cities. Site one had a jump in Health Assessments from 2009 to 2010 whereas site two did not have a similar increase.

Table 136: Number of Aboriginal and Torres Strait Islander Health Assessments for EverIHI patients, by six month period and site, 2007 to 2012.294

Six month period

Site one (RA1)

Site two (RA1)

Site three (RA2)

Site four (RA3)

Site five (RA3)

Site six (RA5)

2007 Jan-Jun 25 15 17 26 - 82007 Jul-Dec 24 18 7 25 1 122008 Jan-Jun 17 18 13 20 - 82008 Jul-Dec 28 20 6 23 1 192009 Jan-Jun 55 35 16 24 1 112009 Jul-Dec 52 33 6 23 - 232010 Jan-Jun 57 31 15 34 4 172010 Jul-Dec 148 21 19 52 2 442011 Jan-Jun 134 38 39 97 23 622011 Jul-Dec 165 39 20 53 19 442012 Jan-Jun 218 50 45 100 36 952012 Jul-Dec 213 29 58 103 23 59

There was a substantial increase in the number of providers of Health Assessments at all sites between baseline and final stages (Table 137137). There

294 ibid.280


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was also an increase in the number of Health Assessments per provider at all sites, again with the exception of site two.The rate of assessments per provider increased markedly at site five, from the period prior to July 2010 and the period thereafter (Table 138138) and also increased at site six. The rate was essentially unchanged at sites one and three, while it decreased at sites two and four.At all sites, more than 84 per cent of the growth in Health Assessments for the period from July 2010 to December 2012 is attributable to growth in the number of providers.

Table 137: Number of providers295 of Aboriginal and Torres Strait Islander Health Assessments for EverIHI patients, by six month period and site, 2007 to 2012.296

Six month period

Site one (RA1)

Site two (RA1)

Site three (RA2)

Site four (RA3)

Site five (RA3)

Site six (RA5)

2007 Jan-Jun 11 7 4 7 - 32007 Jul-Dec 15 7 5 8 1 22008 Jan-Jun 6 5 7 5 - 52008 Jul-Dec 14 7 2 7 1 82009 Jan-Jun 24 12 6 7 1 42009 Jul-Dec 22 13 3 8 - 82010 Jan-Jun 19 7 4 10 2 32010 Jul-Dec 55 12 10 20 2 152011 Jan-Jun 72 12 12 34 9 132011 Jul-Dec 66 16 12 32 14 172012 Jan-Jun 93 20 15 32 22 152012 Jul-Dec 91 19 19 32 18 15



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Table 138: Average number of Aboriginal and Torres Strait Islander Health Assessments per provider297, by six month period and site, 2007 to 2012.298

Six month period

Site one (RA1)

Site two (RA1)

Site three (RA2)

Site four (RA3)

Site five (RA3)

Site six (RA5)

2007 Jan-Jun 2.3 2.1 4.3 3.7 - 2.72007 Jul-Dec 1.6 2.6 1.4 3.1 1.0 6.02008 Jan-Jun 2.8 3.6 1.9 4.0 - 1.62008 Jul-Dec 2.0 2.9 3.0 3.3 1.0 2.42009 Jan-Jun 2.3 2.9 2.7 3.4 1.0 2.82009 Jul-Dec 2.4 2.5 2.0 2.9 - 2.92010 Jan-Jun 3.0 4.4 3.8 3.4 2.0 5.72010 Jul-Dec 2.7 1.8 1.9 2.6 1.0 2.92011 Jan-Jun 1.9 3.2 3.3 2.9 2.6 4.82011 Jul-Dec 2.5 2.4 1.7 1.7 1.4 2.62012 Jan-Jun 2.3 2.5 3.0 3.1 1.6 6.32012 Jul-Dec 2.3 1.5 3.1 3.2 1.3 3.9

297 Up to June 2010, this is the minimum number of individual providers of Aboriginal and Torres Strait Islander Health Assessments. The actual number of providers may be higher as multiple MBS items were used for these assessments. After June 2010, this is the actual number of providers of MBS item 715.298 MBS data supplied by the former Department of Health and Ageing, 2013.


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5.2.5 Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3a)Community member consultations suggest that the PIP Indigenous Health Incentive had a variable impact on patients across the sites. This is consistent with the PIP Indigenous Health Incentive registration data. Across the sites, the patient registration rates varies, ranging from 19.5 per cent of the estimated Aboriginal and Torres Strait Islander population with chronic disease being EverIHI (site five) to 100 per cent (sites three and four). See Table 139139 below.

Table 139: Site population and PIP Indigenous Health Incentive registration statistics.299

Site Aboriginal and/or Torres Strait Islander population (2011 Census) 300

Estimated number of Aboriginal and/or Torres Strait Islander population with a chronic disease(2011 Census and AIHW) 301,302

Patients (EverIHI)303

Estimated proportion of ATSI with CD registered304

Site one (RA1)

11,503 2987 1,484 49.68%

Site two (RA1)

3,302 905 411 45.40%

Site three (RA2)

1,309 347 348 100.00%

Site four (RA3)

1,654 422 515 100.00%

Site five (RA3)

3,653 992 190 19.15%

Site six (RA5)

1,104 289 217 74.85%

299 Australian Bureau of Statistics 2012, 2011 Census of Population and Housing Table Builder, ABS Canberra; MBS data supplied by the former Department of Health and Ageing, 2013; Australian Institute of Health and Welfare, Chronic diseases data, viewed 28 June 2013, <http://www.aihw.gov.au/chronic-diseases/>.300 Australian Bureau of Statistics 2011.301 ibid.302 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.303 This is defined as the maximum number patients who have registered and received at least one MBS service in a given six month period. As such, the Patients (EverIHI) values may not always match the numbers in the proceeding tables.304 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.


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While many patients engaged during final stage consultations reported they were registered for the PIP Indigenous Health Incentive, not all of them had, or knew whether they had, a care plan. Only some of the PIP Indigenous Health Incentive registered patients consulted indicated that their care plan was active. Some were working with a Care Coordinator and others were not, some had accessed specialists and allied health providers (AHPs) and some had never seen these types of providers.There was variable utilisation of MBS item follow on items by EverIHI patients. Overall, there was minimal increase in access to M11 items305, but a high increase in M13 items306 between baseline and final stages. EverIHI patients in sites three and six only received a very small volume of allied health services through MBS. Site one patients received the most allied health services of any site but these services were overwhelmingly billed through group M3; see Table 140140 below.

Table 140: Allied health services by year and site.307

Site Group & Subgroup

2007 2008 2009 2010 2011 2012

Site one (RA1)

M03XX 93 140 209 332 459 507M11XX - - 10 5 27 35

Site two (RA1)

M03XX 20 17 27 47 74 94M11XX - - 1 17 20 31

Site three (RA2)

M03XX 13 23 20 29 30 33

Site four (RA3)

M03XX 21 54 53 97 123 201M11XX - - - - 14 86

Site five (RA3)

M03XX 3 13 24 44 52 70M11XX - - - - - 6

Site six (RA5) M03XX 2 2 2 6 12 6M11XX - - 1 - - 1

The lower billing of allied health services in the remote site (site six) was expected due to factors such as limited services being provided, fewer people with chronic disease due to the young population profile, and the high availability of free outreach services funded by state governments.

305 These are allied health follow on items for Aboriginal and Torres Strait Islander people. 306 These are non-Aboriginal and Torres Strait Islander-specific allied health follow on items. 307 MBS data supplied by the former Department of Health and Ageing, 2013.


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5.2.6 Supporting Primary Care Providers to Coordinate Chronic Disease Management (B3b)The CCSS program had a significant impact on the patient journey by supporting transition of patients more easily from primary to secondary services. It did this by: providing patients with support to understand and navigate the system (Care

Coordinators); and addressing some of the significant barriers to accessing required care like

transport and costs of appointments (SS funds).

5.2.7 Improving Indigenous Participation in Health Care through Chronic Disease Self Management (B4) There is little data available to assess the impact of this measure at the sites – providers at three sites (site three, four and five) had undertaken the training but only those at sites four and five had implemented the training with patients. No patients consulted by the evaluation had been involved in Chronic Disease Self Management (CDSM) with a provider.

5.2.8 Increasing Access to Specialist Care (B5a) At site two, USOAP services are now operating as planned, though engaging and contracting specialists took longer than expected. Community members commented that accessing specialists at the AHS was highly valued and, in many cases, said they would have been unlikely to go to specialist appointments if they were based elsewhere, such as at a hospital outpatient department because of negative past experiences.

5.2.9 Increasing Access to Specialist and Multidisciplinary Team Care (B5b)At sites four and five, where MSOAP-ICD was operational, it provided patients with alternative options to access specialist and allied health services. At site four, MSOAP-ICD and CCSS together met a great need for access to specialist and allied health services and significantly affected patient access to required follow up services for chronic disease management.

5.2.10 Workforce Support, Education and Training (C1)No organisations at any of the six selected sites reported that they had been involved in the GP Registrars or nursing placements components of this measure. Most ATSIOWs consulted had undertaken some orientation and/or training, and said this had assisted them to understand their role and enhanced their capacity to fulfil their role. There was no direct evidence of the impact of this on patients, but it is likely that having more skilled workers will lead to improved patient care.


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5.2.11 Expanding the Outreach and Service Capacity of Indigenous Health Organisations (C2)The ATSIOW employed in the AHS in site four was focused on increasing community members’ awareness of the services available through the AHS, and increasing patient access to the AHS. This ATSIOW was new but had already supported increased patient access to primary and secondary health care services provided through the AHS. The most important support this worker was providing, from the patient perspective, was transport support. The two ICDP practice managers consulted (sites one and four) had not focused on PBS Co-payment or PIP Indigenous Health Incentive participation, so it is unlikely they affected patient engagement with these initiatives. Rather, their focus was on improving the functioning of the AHS to enable the AHS to provide more comprehensive, streamlined and better quality patient care.

5.2.12 Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care (C3)Similarly to the C2 measure, the ATSIOWs supported patients to engage with primary and secondary services to meet their needs by addressing barriers such as transport. IHPOs increased awareness of the ICDP amongst mainstream providers, advocated for and thus raised provider awareness about Aboriginal and Torres Strait Islander health and supported some improvements in the cultural appropriateness of services.

5.2.13 Attracting More People to Work in Indigenous Health (C4)While there was some awareness of this measure amongst the Aboriginal and Torres Strait Islander health workers consulted, no workers indicated that it had impacted on their decision to take on their current role.

5.2.14 Clinical Practice and Decision Support Guidelines (C5)The website was not ‘live’ when final stage consultations were conducted.

5.2.15 Summary Comparison with other sitesThere was broad consistency in the observed impacts of ICDP measures between the evaluation sites and the selected Sentinel Sites; thus, the findings are likely to be consistent with findings at other comparable locations.


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One of the factors that contributed to this consistency is the similarity in the models of ICDP activity observed at the evaluation sites and the Sentinel Sites predominantly with respect to ICDP funded workforce: ‘typical’ ICDP worker roles were observed across many sites, for example

ATSIOWs commonly had a role in providing support to patients in the form of transport, advocacy, encouragement and raising awareness of the ICDP – the roles of Care Coordinators, IHPOs and RTSHLTs were also observed to be consistent across sites;

in the remote evaluation site and SSE sites, ICDP workers had more generalist responsibilities as designed by their organisations – this responded to the smaller number of workers and narrower range of services in these remote locations, and the need to address gaps associated with this;

a team approach was adopted for ICDP workers across both evaluation and Sentinel Sites, commonly including ATSIOWs, IHPOs and Care Coordinators, who worked together to meet a broader range of patient needs. ICDP workers like ATSIOWs also supported the SOAP clinics at both evaluation and Sentinel Sites;

the IHPOs focused on engaging mainstream practices that participated in the PIP Indigenous Incentive to encourage them to modify their practices and procedures beyond the requirement for two staff to undergo cultural awareness training; for example, establishing a dedicated clinic for Aboriginal and Torres Strait Islander people and having more flexible appointment arrangements.

5.3 Ongoing challenges A number of ongoing challenges were observed which limited the utilisation and reach of the ICDP measures, and presented barriers within the patient journey.

5.3.1 Differing levels of ICDP investmentDiffering levels of investment across locations is part of the design of the ICDP308, however this translated to varied impacts on the patient and the system across sites.Where patients had access to services that were strongly aligned with the challenges and barriers they were experiencing, the improvement to their patient journey was more marked. For example, transport was a commonly identified and significant barrier, which various aspects of the ICDP (namely ATSIOWs and CCSS Program) aim to address. Patients who did not have access to these measures still struggled at the final stage to access services, based on limited transport. In some sites, such as site three, access to transport supports varied within the region. In this site, the assistance of the ATSIOW and Care Coordinator led to increased access to services for Aboriginal and Torres Strait 308 ICDP investment was directed based on factors like the perceived need of the community, level of existing investment, population size and characteristics. Indigenous Health Partnership Forums in each jurisdiction were heavily involved in this process.


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Islander people living in the town, but limited access to these workers meant similar improvements were not realised for people in the discrete Aboriginal community. The level of access in some sites was restricted due to the location of services and distances between where people live and where services are delivered. For example, the ICDP investment in site four is dispersed across the region and this led to variable access for patients depending on where they lived.

5.3.2 Contextual factors at the site-levelA number of site-level contextual factors were observed at final stage, which presented ongoing challenges: Larger regions were reported to be more difficult for workers to cover,

particularly workers with region-wide outreach roles such as RTSHLTs, ATSIOWs and Care Coordinators.

Population mobility, because some sites had highly mobile populations (e.g., sites one, two and three) which limited the regularity with which community members could engage with services.

Lack of cultural appropriateness as the individual site information shows, the cultural appropriateness of general practices remains varied despite overall improvements as a result of the ICDP (in particular the introduction of the PIP Indigenous Health Incentive measure and IHPOs). This affected some patients’ willingness to access ICDP services provided in mainstream settings.

5.3.3 Community demand and expectationsIssues relating to community demand and expectations were also observed at final stage: Difficulty to meet demand in some places. Workers placed in areas where

community members had, or considered they had, high needs were in great demand and under considerable pressure to meet demand. For example, in site four there was a particularly high demand for access to SS funds to support access to specialists and this contributed to significant pressure on the local Care Coordinator. Community members who had access to the Care Coordinator at this site identified positive changes in their journey, however for others access to specialists was still reported as a gap.

Community expectations. During patient journey mapping and service mapping consultations, some community members noted that their expectations about what ICDP programs should provide were not being met. Commonly, the following unmet needs were identified:- one-to-one smoking cessation support;- access to DAAs through CtG scripts;


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- availability of programs (namely CCSS and PIP Indigenous Health Incentive) for under 15 year olds with chronic diseases such as asthma; and

- use of SS funds for some equipment. There was a perception that because the ICDP was not able to address these needs, the opportunity for the ICDP to improve the patient journey was limited.

Comparison with other sites There is consistency in the ongoing challenges observed between the evaluation sites and Sentinel Sites; thus, the evaluation findings are likely to be consistent with findings at other comparable locations. Similar to the evaluation sites, there were differing levels of ICDP investment

at the Sentinel Sites; in particular, there was less investment in remote sites E and F. This meant that community members at these sites had access to a narrower range of ICDP programs than at others.

Site level contextual factors at the Sentinel Sites including large regions (sites C, D, E and F), population mobility (mostly at the remote sites but also some at the urban and regional sites) and remaining cultural inappropriateness (all sites), presented similar ongoing challenges to those observed at the evaluation sites.

At both the evaluation sites and Sentinel Sites, community demands and expectations impacted on community perceptions of the value they received from the ICDP – for example at most sites there was a strong suggestion from community members that current transport support (being provided by ATSIOWs) is good but does not meet demand in terms of reaching everyone who needs it. Community members’ perceptions of gaps were also similar at both the evaluation sites and Sentinel Sites, for example across most sites the lack of face to face, Aboriginal and Torres Strait Islander-specific smoking cessation support was considered a gap.309

Additional challenges were identified within the Sentinel Sites at the final stage that were not as strongly apparent in the evaluation sites. The likely factor explaining these additional challenges is timing of data collection.Across all six Sentinel Sites two main issues remained, which were not consistently observed across all evaluation sites, although they were found to be present at some sites and within some services.The first was achieving ‘buy in’. At the final stage (for the evaluation this was early 2013, and for the SSE this was mid 2012) there was still limited commitment to the ICDP from some services (e.g., GPs and pharmacies); as indicated by resistance to engage with the ICDP (e.g., to register for the PIP Indigenous Health Incentive and dispense CtG scripts). There was also

309 RTSHLTs generally have a focus on group and community level engagement rather than individualised support.


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unwillingness within some services to invest in making changes to be more culturally appropriate, such as GP practices implementing systems to identify Aboriginal and Torres Strait Islander patients. The second issue was limited awareness about the ICDP. Across the Sentinel Sites there was still limited awareness of the ICDP amongst community members and (some) service providers at final stage: amongst community members limited awareness of the rationale and benefits

associated with registering for the PIP Indigenous Health Incentive was observed, as well as general confusion about what the ICDP constitutes; and

amongst some service providers, a lack of understanding about why they should engage with the ICDP was apparent; particularly amongst those providers who perceive they do not have many or any Aboriginal and Torres Strait Islander patients.

Overall, the evaluation found that limited awareness and buy in were issues associated mostly with the earlier stages of implementation; these issues were largely non-existent in the evaluation sites by early 2013 when the final round of data collection was undertaken. Whereas the Sentinel Sites data collection occurred in mid-2012 and thus there is a possibility that this may have been a less of an issue by 2013.At the remote Sentinel Sites, specific issues were also identified at final stage. These were largely contextual rather than linked to the ICDP and included: limited infrastructure to support ICDP investment and progress, such as

housing for workers, shops with fresh food; ongoing costs for patients associated with attending appointments where

travel to locations outside of the site is required; and staff recruitment and retention issues – some of which are associated with

lack of housing.These issues were also observed at other remote sites visited as part of the broader ICDP evaluation.

5.4 Contextual influences The final stage consultations highlighted that a number of key factors outside of the ICDP impacted on the patient journey and service system across the sites, sometimes in combination with the ICDP. These key factors included the following. National health reform310 – the establishment of Medicare Locals presented

both facilitators and barriers to the patient journey and service system, which impacted in different ways across sites.

310 Department of Health [9 July 2013], National Health Reform, viewed September 2013 <http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/theme-primarycare >.


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- The requirement on Medicare Locals to engage with the AHSs sector led to enhanced system collaboration in most sites. In one site though, the transition led to DoGP management staff being replaced, and this compromised the existing good relationship between the DoGP and the AHS (site four).

- The requirement on Medicare Locals to provide Aboriginal and Torres Strait Islander health programs extended beyond ICDP programs in some Medicare Locals. For example, in site one, all staff were expected to include a focus on Aboriginal and Torres Strait Islander clients within their programs. This increased the number and range of services targeting Aboriginal and Torres Strait Islander people within the region.

- Medicare Locals across the sites tended to be larger organisations, offering more programs than the DoGP had in the past. This provided opportunities for ICDP workers to link their Aboriginal and Torres Strait Islander patients in with a broader range of internal services and supports. This made some transitions through the system easier for patients, and improved the capacity of the system to coordinate care.

State and territory Closing the Gap programs – in a number of sites, state and territory Closing the Gap programs were in place, which ICDP workers were able to link with or leverage to the benefits of patients and the system. For example:- in site three, the state and territory Closing the Gap-funded Aboriginal

Health Workers (AHWs) were working closely with the ICDP workers as part of a ‘Closing the Gap team’. By bringing together the AHWs, who could provide screening and other clinical services, with the ATSIOWs, who could support patients to access services and understand their care needs, a broader range of patient needs could be met.

Other national or state and territory programs and services – similarly, there were a number of other programs and services operating in the sites with similar aims to the ICDP, that the ICDP could leverage. For example:- in site one, the Care Coordinator was receiving Aboriginal and Torres Strait

Islander patient referrals from a state-funded care coordination program (this Care Coordinator’s position was partly funded through the ICDP and partly funded through this state-funded program, and she worked closely with both ICDP workers and the state-funded care coordination program staff). The state-funded program was mainstream, thus, through referrals to the Care Coordinator, patients had access to an Aboriginal and Torres Strait Islander-specific program, which they considered better able to better meet their needs.

This example illustrates that programs with complementary aims can provide opportunities for synergies which can lead to some improvements to the patient journey and service system capacity. National and state and territory policy maps which set out the policies and initiatives with similar aims to the ICDP, are provided in the Appendices to Volume 1 of this report.


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Appendices

Appendix A: Patient journey mapping and service mapping site selectionSix community sites were selected for patient journey (and service) mapping. These sites were selected from the eight initial communities identified in consultation with the department for community site visits in late 2011. The selected sites provide coverage across states and territories, and allow for data collection from communities with different characteristics. In particular, the following criteria were used to select the patient journey mapping sites: the geographical location of the site (with the aim of achieving a mix of urban,

regional and remote areas); the ICDP activity in place at the site (with the aim of accessing sites with

varied levels and a range of ICDP activity in place); and the Aboriginal and Torres Strait Islander population (sites with a moderate to

high population were selected, to enable adequate data to be collected).In accordance with our ethics approval, the six sites selected are not identified in this document. The sites selected include: two urban sites; one inner regional site; two outer regional sites; and one remote site.


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Appendix B: Data collectionB.1 Stakeholder consultationsDuring the site visits a range of stakeholders, including Aboriginal and Torres Strait Islander community members, were consulted to inform both patient journey mapping and services mapping. For service providers, patient journey mapping- and services mapping-related questions were generally incorporated into whole of evaluation consultations. For community members, specific patient journey mapping and service mapping focus groups were held. A decision was made to consult with community members and service providers separately in order to allow the participants to speak openly and truthfully. The consultations with health service providers sought their perspectives on: The common experiences of Aboriginal and Torres Strait Islander chronic

disease patients at each site, across community, primary, secondary and tertiary health care settings. This included identification of facilitators and barriers to accessing health care, and to receiving good practice chronic disease care.

The degree to which the health service system functioned effectively. Health service providers were asked to comment on things that worked well and areas for improvement (i.e., facilitators and barriers), as well as the impact of these facilitators and barriers on the health service system at the site.

The likely or actual change to the patient journey and service system at that site caused by the introduction of the ICDP. An organisational survey was also administered to health service providers. See the following section for details.

Community members participated in patient journey mapping and service mapping focus groups that covered: chronic disease prevention and risk factors (this was framed as series of

questions about community lifestyle such as exercise, smoking, access to health food and attitudes to lifestyle choices);

access to primary health care and chronic disease diagnosis; and chronic disease management and access to secondary and tertiary health

services.Again, there was a focus on the functioning of the health system, through discussion of barriers and facilitators. The evaluators also used questioning in the final round to understand the changes that had resulted for patients based on the introduction of the ICDP.It is important to note that community members were recruited for consultation via convenient sampling, and the number of community members engaged is small relative to the population size of the sites. Patient experiences are therefore not necessarily representative of the views of all community members


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either within the selected sites, or more broadly across the Aboriginal and Torres Strait Islander population.All consultations were conducted with reference to the domains and characteristics of the conceptual framework. Details about the number of consultations undertaken during this patient journey mapping and service mapping site visits are provided below in Table 141141.

Table 141: Overview of stakeholders consulted during six patient journey mapping and service mapping site visits.Site Service provider stakeholders

consultedFocus groups conducted

One (RA1) baseline

Mainstream sector: IHPO, ATSIOW, Care CoordinatorAHS sector: RTC, TAW, HLWs (2), CEO, Chronic Care Team (2)

Group one: Ten participants, seven female, three male, age range 18-70Group two: Eleven participants, six female, five male, age range 30-75

One (RA1) final

Mainstream sector: IHPO, ATSIOWs (2), AHW, Care Coordinator, Director, GPAHS sector: RTC, TAW (2), HLW (1), ICDP practice manager

One focus group: Eight participants, three female, five male, age range 30-65

Two (RA1) baseline

Mainstream sector: IHPO, ATSIOW, other connected team members, CEOAHS sector: TAW, Clinical manager, medical officer

One focus group: Seven participants, females, age range 25-70

Two (RA1) final

Mainstream sector: IHPO, ATSIOW, other connected team membersAHS sector: TAW (2), HLWs (3), management staff, Medical Director, medical officer, pharmacist

One focus group: Eight participants, six female, two male, age range 25-70

Three (RA2) baseline

Mainstream sector: IHPO, ATSIOW, Care Coordinator, AHWs (2), local GPAHS sector: Executive Officer, RTC TAW, HLWs (2), management staff; Aboriginal and Torres Strait Islander Health (2), AHW

One focus group: Three participants, all female, age range 65-70

Three (RA2) final

Mainstream sector: ATSIOWs (3), Care Coordinator, AHW, Director, GP (2)Pharmacists (2), Practice manager (2)AHS sector: RTC, TAW, HLWs (2), Management staff – Aboriginal and Torres Strait Islander health (3), nurse, Outreach provider, MSOAP-ICD program manager

One focus group: Five participants, all female, age range 20-59

Four (RA3) baseline

Mainstream sector: IHPO, ATSIOW, Care Coordinator

Group one: Three participants, two female, one male, age range 45-60


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Site Service provider stakeholders consulted

Focus groups conducted

AHS sector: Operations Manager, practice manager, dietician, diabetes educator

Group two: Five participants, all male, age range 28-75

Four (RA3) final

Mainstream sector: IHPO, ATSIOW, Care Coordinator, Aboriginal programs manager, Director, MSOAP-ICD program manager, MSOAP-ICD provider, GPs (2), pharmacists (2)AHS sector: ICDP practice manager, RTC, TAWs (3), HLWs (2), ATSIOW

One focus group: Nine participants, four male, five female, age range 21-65

Five (RA3) baseline

Mainstream sector: IHPO, ATSIOW, Care Coordinator, other connected team members CEO

Group one: Seven participants, five females and two males, age range 26-63 yearsGroup two: Six participants, three males, three females, age range 23-60 years

Five (RA3) final

Mainstream sector: IHPO, ATSIOW, Care Coordinator, other connected team members CEO

Group one: Seven participants, five females and two males, age range 26-63 yearsGroup two: Six participants, three males, three females, age range 23-60 years

Six (RA5) baseline

Mainstream sector: IHPO, ATSIOWs (4) local GP, practice staff, pharmacistAHS sector: nursing staff (2), acting CEO and CEO

Group one: Nine participants, three males, six females, age range 20-70Group two: Eight participants, six females, two males, age range 20-70

Six (RA5) final

Mainstream sector: Care Coordinator, ATSIOWsAHS sector: AHW, ATSIOW, CEO and service manager

One focus group: Eight participants, six female, two male, age range 30-65

B.2 Organisational surveyService mapping was further informed by an organisational survey that was administered to key health service providers and organisational representatives during site visits. For most stakeholders the survey was completed during a face-to-face consultation, while for others chose to complete the survey after the site visit and send it to the evaluation team. This survey collected data about the capacity and scope of key organisations in the region, including regional boundaries, types of programs provided, target groups, staff numbers, facilities and funding. Scaled questions (scales from one to 10) were also included that related to the strength of partnerships with other services which have common clients and the strength of the service system overall in terms of collaboration. The data in this survey complemented the information collected during stakeholder consultations about the service system.


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B.3 Research and literature reviewResearch and literature review was undertaken to inform an analysis of the national health system (see B.3 Research and literature review) and the development of the conceptual framework (see The conceptual framework). A range of policy and program documents were examined to develop the national health system analysis, the purpose of which was to provide an overview of the national service system at baseline and final (the latter is included in this document). This supported the analysis of contextual considerations on the patient experience and local service systems at the six sites. The conceptual framework was designed to support a structured approach to the presentation of information, and analysis of the service system and the patient experience. To develop the conceptual framework a targeted literature review was undertaken to identify common factors relevant to patient journey mapping and service mapping. These include: service system capacity; access to health care by Aboriginal and Torres Strait Islander people; cultural factors influencing access to health care; the appropriateness of services for Aboriginal and Torres Strait Islander

people; the role of the health workforce in delivering appropriate services; communication and service coordination; best practice chronic disease care; and continuity of care. Finally, the research and literature review was also used to inform the presentation of the patient journey mapping and service mapping document. A number of existing patient journey maps and service maps were assessed and common components were identified and then incorporated, such as the flow diagram-style patient journey maps and the quotes from patients about their experiences.

B.4 Secondary data sources Patient journey mapping and service mapping was also informed by analysis of location-based secondary data sources including: population data from the Australian Bureau of Statistics; the Office for Aboriginal and Torres Strait Islander Health (OATSIH) Services

Reports (OSR); MBS data; PBS data; and


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PIP Indigenous Health Incentive data. These three data sources were supplied by the department. Discussion in this document focuses on the MBS data and the PIP Indigenous Health Incentive data. Other data sources include Aboriginal and Torres Strait Islander population estimates from the Australian Bureau of Statistics (ABS)311, rates of chronic disease by age groups (Australian Institute of Health and Welfare, AIHW)312 and numbers of AHSs313. These data sources are generally used to provide context to the estimates from the proportion of Aboriginal and Torres Strait Islanders that have registered for the PIP Indigenous Health Incentive.The relevance of these data sources to patient journey mapping and service mapping, and their limitations, are identified in Table 142142. Throughout the body of this report, where OSR, MBS and PBS data have been sourced for these sites, the timeframe for that data is identified.

311 Australian Bureau of Statistics 2008, 3238055001DO004_200606 Experimental Estimates of Aboriginal and Torres Strait Islander Australians, Jun 2006, ABS cat. no. 3238.0.55.001, Canberra.312 Australian Institute of Health and Welfare, n.d. Chronic Diseases (website ), viewed 18 October, 2012, <http://www.aihw.gov.au/chronic-diseases/>.313 Australian Institute of Health and Welfare 2011. Aboriginal and Torres Strait Islander health services report 2009–10: OATSIH Services Reporting—key results. Cat. no. IHW 56. Canberra: AIHW.


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Table 142: Data sources utilised to inform patient journey mapping and service mapping.Area of enquiry

Relevance to PJM and SM Data source and summary of analysis Limitations and notes

Aboriginal and Torres Strait Islander population

Understanding of the population profile in each of the six sites.

Resident population and Aboriginal and Torres Strait Islander population (2011 Census)314 and rates of chronic disease by age groups (AIHW)315.Census data was used to provide information about the total Estimated Resident Population by Aboriginal and Torres Strait islander status, and the proportion of population identifying as Aboriginal and Torres Strait Islander, for each site. AIHW data was used to provide information on the estimated rates of chronic disease amongst the population at each site. This data was reported and used in conjunction with PIP Indigenous Health Incentive registration statistics for each site to understand the proportion of patients that had registered.

A decision was made to use 2011 Census data given that it is not possible to access 2009 or 2010 Estimated Resident Population at the site level by Aboriginal and Torres Strait Islander status. There are a number of issues and limitations with Census data, which are detailed on the ABS website.316

314 Australian Bureau of Statistics 2012, Census of Population and Housing: Basic Community Profile Data Pack (online) 2011 First Release, Cat. no. 2069.0.30.001, ABS, Canberra.315 Australian Institute of Health and Welfare 2013, Chronic Diseases (website), viewed 18th October 2012, <http://www.aihw.gov.au/chronic-diseases/>.316 Australian Bureau of Statistics 2012, Census of Population and Housing – Counts of Aboriginal and Torres Strait Islander Australians, 2011 , cat no. 2075, ABS, Canberra, viewed 18 October 2012, <http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/2075.0Explanatory%20Notes12011>.

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Area of enquiry


Provision of services to Aboriginal and Torres Strait Islander people within sites

Understanding of the level of provision of and access to key services that the ICDP is trying to influence. These include PIP Indigenous Health Incentive care plans, Aboriginal and Torres Strait Islander Health Assessments and professional and pathology services.

Proportion of Aboriginal and Torres Strait Islander residents registered for PIP Indigenous Health Incentive (EverIHI)317

The combined MBS and PIP Indigenous Health Incentive data is collated by the Department of Human Services (previously Medicare). It consisted of the number of patients ever registered for the PIP Indigenous Health Incentive (‘EverIHI patients’) and the services these patients received for relevant time periods. The number of EverIHI patients was compared to the Aboriginal and Torres Strait Islander population of each site to estimate the proportion of the population that registered for the initiative.

EverIHI is defined as the maximum number patients that have registered and received at least one MBS service in a given six month period. As such, the Patients (EverIHI) values may not always match across tables.

Number of Aboriginal and Torres Strait Islander Health Assessments by site.318.The MBS and PIP Indigenous Health Incentive data is collated by DHS. It consisted of the number of EverIHI patients and the MBS services these patients received during the period from 2007 to 2012.The Aboriginal and Torres Strait Islander

The ICDP aims to increase access to MBS item 715 (e.g., through ICDP workers facilitating patient access to a GP for a Health Assessment). However, the ICDP is not the only factor influencing actual access to Health Assessments and MBS claiming. Other factors may include programs external to the ICDP which aim to increase Aboriginal and Torres Strait Islander peoples’ access to Health Assessments, and changes in

317 Medicare Australia, PIP Indigenous Health Incentive data about patients ever registered by June 2011, provided by Medicare Australia, through the former Department of Health and Ageing to KPMG in 2011.318 Medicare Australia, Number of Aboriginal and Torres Strait Islander Health Assessments by site in 2009-10, provided by Medicare Australia, through the former Department of Health and Ageing to KPMG in 2011.

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Area of enquiry


Health Assessment is an MBS item (item 715) for a service that can only be provided to Aboriginal and Torres Strait Islander patients. This is one of the items (in conjunction with the previous Aboriginal Health Assessment Items 704, 706 708 and 710) provided in the data.

practices’ level of claiming (i.e., due to a new provider coming on board, or a change in management at a health service). Further, not all patients may self identify as an Aboriginal and Torres Strait Islander person (a requirement of MBS item 715) and health services might undertake a Health Assessment and not claim against the MBS.Thus this data may under-represent the actual number of Health Assessments or equivalent being performed in the sites.

Number of professional services and pathology services.319

The MBS and PIP Indigenous Health Incentive data is collated by the Department of Human Services. It consisted of the number of EverIHI patients and the services these patients accessed.MBS data consists of categories, groups and items. For example, Item 715, which is an Aboriginal Health Assessment, sits within the group A14 Health Assessments, which sits within the category of Professional attendances. There are many other items within the Professional attendances category. Likewise for the pathology services category.

The ICDP aims to increase access to not only Health Assessments but to improve the standard of care for Aboriginal and Torres Strait Islander people with chronic disease. Analysing the number and range of services that EverIHI patients receive provides an indication that the standard of care has improved. The main limiting factor of MBS claims data is that it only indicates whether a service provided was claimed and not the standard of that service.However, the ICDP is not the only factor influencing actual access to primary health care. Other factors may include programs external to the ICDP which aim to increase Aboriginal and Torres Strait Islander peoples’

319 Medicare Australia, Number of professional services and pathology services in 2009-10, provided by Medicare Australia, through the former Department of Health and Ageing to KPMG in 2011.

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Area of enquiry


Analysis of the Professional Attendances and Pathology services category involvedNumber of professional attendances and pathology services by site.

access to primary health care, and changes in practices’ level of claiming (i.e., due to a new provider coming on board, or a change in management at a health service).It is also possible that services are provided to Aboriginal and Torres Strait Islander people under items which are not Aboriginal and Torres Strait Islander specific, either because the individual has not identified/been identified as Aboriginal and Torres Strait Islander or because the provider chooses not to use an Aboriginal and Torres Strait Islander specific item.

Overview of Aboriginal and Torres Strait Islander health service system

Understanding the profile of the Aboriginal and Torres Strait Islander health service system with specific reference to the areas in which the ICDP will lead to, or has led to change (e.g., staff, types and scope of services provided).

Office for Aboriginal and Torres Strait Islander Health (OATSIH) Services Reports (OSRs).Services funded by OATSIH are required to complete an annual questionnaire called the OATSIH Services Report (OSR). This provides information on activities, clients, provision of care, staffing, substance use, Bringing Them Home, and Link Up counselling services. A specific OSR data request was provided to obtain data for four of the six sites This data was not analysed, rather it was reported.

Summary reports based on each annual OSR are available through the AIHW. These reports do not present data in a way that may identify an individual organisation. Organisational level data can only be accessed if the organisation gives specific consent for the information to be released. Such consents were sought from each of the AHSs consulted through the site visits, and data was provided accordingly.There are a number of key limitations to the OSR data.Fluctuations in staff numbers are difficult to attribute to any one program (ICDP or others) with certainty, given the multitude of factors likely to impact on the staff profile of

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Area of enquiry


AHSs at any given time.Counting rules vary across services, for example, ATSIOWs may be counted under the category of AHWs or Medical Specialists and other Allied Health Professionals.There is an approximate 12 to 15 month time lag between the reference period and the publication of information.The AIHW considers that some data presented in the OSR — particularly around client numbers, episodes of care and client contacts — are estimates of actual figures, and should be used and interpreted with caution.The OSR only provides information on whether a service offers a type of service (e.g., tobacco control program) and not the number of clients accessing these services or the volume of these services.Further, upon the receipt of this data, a number of issues were apparent, for example recording of client and episode information is poor, and different staff filling in the OSR seems to have led to inconsistency in data.

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Appendix C: Analysis C.1 Analysis of data at the site levelPatient journey mapping and service mapping harnessed multiple data sources to provide insight into patient experiences and the Aboriginal and Torres Strait Islander health service system at each site. Some of the methods and data sources described in the previous section provided quantitative (and in some cases empirical) information about the Aboriginal and Torres Strait Islander population and the services available to community members at the site. These methods and data sources include both secondary data and the service survey. In some cases data was reported whereas in other cases specific analyses were undertaken. Largely this data fed into the written components of the patient journey and service system maps in the individual chapters. The individual service surveys were used to inform the service mapping, including the visual maps and the discussion in the individual chapters. Other methods and data sources described in the previous section provided qualitative information about the subjective experiences and perceptions of patients and service providers. This information was used as an overlay to the quantitative information. Subjective interpretations of stakeholders were considered according to the three domains introduced in the conceptual framework. More specifically, the notes taken at stakeholder consultations were subject to thematic analysis and were checked against the conceptual framework in order to ensure thorough consideration of all the factors. This analysis resulted in identification of common facilitators and barriers or limiting factors relevant to the patient journey and service system. Those facilitators and barriers explicitly identified by health service providers and community members also informed the identification of these common facilitators and barriers. The subjective experiences were used to inform the visual and written components of the both the patient journey and service maps within each chapter.

C.2 Assessment at different levelsPatient journey mapping and service mapping provides an opportunity to consider the findings at three levels: site specific, geographical (i.e. urban, regional, remote), and national.At the Baseline stage, the emphasis was on understanding the patient journey and service system pre-ICDP, and the likely impact of the ICDP once the measures have been implemented at all three levels. At the Final Report stage, the emphasis was on identifying the impact of the ICDP. Specifically, it looked at whether change has occurred; if so, in what areas; and what factors have facilitated or inhibited this change. Again, was done at all three levels. The methods to support the translation from site level to regional and national level at each stage are set out in Table 143143.


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Table 143: Methods to inform assessment at different levels.Stage Method What will this tell us? ApproachBaseline Identifying

indicators of change and variation trends.

Indicators of change are signs that change is likely to occur or has occurred (i.e. early changes have been observed that can be linked to specific factors) as a result of the ICDP.Identifying trends by variations in remoteness and other factors shows how specifically the ICDP is likely to affect change across different locations (i.e. how the information at the six sites translates into regional themes).

A number of common indicators of change were identified during the site visit consultations and the subsequent development of patient journey and service maps. Common indicators were recorded for each site, with reference to the conceptual framework domains and characteristics. An analysis across sites was then undertaken identifying: commonly experienced indicators and any variations by remoteness and other factors such as sector. The areas in which change is likely to occur as a result of the ICDP were identified at each site are discussed in the individual site chapters. The patient journey maps also highlight barriers that are likely to be addressed as a result of the ICDP at that site.

Corroboration of findings with internal data.

Whether the indicators of change identified at the six sites, are evident elsewhere and are showing similar early linkages to change, suggesting broader applicability of these indicators.

Analysis of other data collected during Baseline community site visits was assessed, to identify whether the common and the context specific indicators were present in locations other than the six patient journey mapping and service mapping sites. Information from two other sites visited at baseline was assessed as part of this corroboration process. This assessment showed broad consistency with the indicators of change identified.

Final stage Identifying changes that occurred between Baseline and Final Report stages, and again, identifying variation trends.

Identifying changes between the two stages of patient journey mapping and service mapping highlights the areas in which the ICDP may have affected change

Identifying changes that occurred between Baseline and Final Report stages involved:re-applying the methods described in the sections above to collect and analyse data at the site level;developing final patient journey and service maps including surrounding discussion focused on ICDP investment and the actual impacts of the ICDP in each site;through analysis and synthesis of data at each site, assessment of whether the

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Stage Method What will this tell us? Approachindicators for change remain relevant (i.e., are still present) and whether changes have occurred that can be linked to these indicators;comparison across sites considering common changes and variation trends, as well as the relative progress of the ICDP across sites.

Assessing the likelihood that findings will be consistent with findings at other comparable locations.

Whether external research projects, namely the Sentinel Sites Evaluation (SSE), has found similar changes resulting from the ICDP to the patient journey and service system.

See Appendix C: Analysis

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C.3 Limitations Patient journey mapping and service mapping rely heavily on consultation with a small number of stakeholders in six sites. These sites and the participating stakeholders are not representative samples. Therefore, the findings at these sites are not necessarily directly applicable to other locations, and broad conclusions about rural, regional or urban sites cannot be drawn through these site-specific profiles alone. This limitation is addressed, however, by bringing together multiple sources of data and corroborating and validating the data, as described above.The baseline analysis cannot exactly match the 2009-10 timeframe for the Baseline Report, as the evaluation did not commence until late 2009-10. During the stakeholder consultations (undertaken November and December 2011), participants were asked to reflect on the service system in 2009-10, however it is unreasonable to expect community members and stakeholders to accurately recollect that time period. In addition, there are a range of data limitations that are described in Table 142144.

C.4 Assessment of comparabilityTo understand the extent to which the patient journey and service mapping findings are likely to be consistent with findings at other comparable locations KPMG worked with Menzies School of Health Research, the conductors of the Sentinel Sites Evaluation (SSE).This involved selecting six of the 24 Sentinel Sites, which were comparable to the six patient journey and service mapping sites discussed in this report (also referred to as the evaluation sites). They are referred to in this report as ‘the Sentinel Sites’ or sites A-F. The six Sentinel Sites were selected so that, together with the six evaluation sites, there was broad coverage of jurisdictions, remoteness areas (urban, regional and remote) and service delivery through the mainstream and AHS sectors. The SSE did not commence in all sites at the same time; the selection of sites for this comparison activity also prioritised those sites where data collection had started earlier, to fulfil the requirement to reflect on a ‘baseline’ period. Menzies School of Health Research reviewed data previously collected in the course of the SSE, and then undertook analysis of that data comparable to that undertaken for patient journey and service mapping. Comparison of the findings from the evaluation sites and the Sentinel Sites was then undertaken in relation to: site level outcomes; remoteness area outcomes; and overarching themes.


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This analysis informed a view about the extent to which findings from the evaluation sites are likely to be consistent with findings at other comparable locations. This Appendix presents the outputs of the assessment where further information is required to complement what is included in the body of this document.

C.4.1 Changes as a result of the ICDPThe tables below present: the common and variable changes observed at the evaluation sites at final

stage as a result of the ICDP (middle columns) based on the changes that were expected (first columns); and

a summary of whether or not these were observed at the Sentinel Sites at final stage (second columns).

These tables expand on the summary relating to changes observed at final stage compared to those expected, in chapters Error: Reference source not found and 5.


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C.4.2 Changes which were expected to occur at all sites

Table 144: Assessment of the changes observed as a result of the ICDP at final stage.Common changes expected at evaluation sites at baseline

Common changes observed at evaluation sites at final stage

Observed across Sentinel Sites at final stage?

Increase in number of staff working in Aboriginal and Torres Strait Islander health.

The ICDP led to between 3 (site six) and 12.25 (site one) additional FTE staff in each site. However, community members engaged through focus groups reported gaps relating to staffing numbers, e.g., the high demand on workers such as ATSIOWs led to not all patients being able to access these workers and their services.

Yes: Across the Sentinel Sites there was a change in the number of FTE staff at ICDP funded organisations of between 3.55 (site C) and 16.5 (site A). There were also increases in the number of staff providing services within AHSs across all of the sites, although these increases cannot be linked to the ICDP. All of the sites except site F had an increase in the number of allied health professionals providing services from the AHS, including the sites that did and did not have SOAP investment. The ICDP through the SOAP measures may have led to some increases, but increases also occurred in the absence of these measures. The number of doctors providing services also increased at all of the AHSs except site E by between 33 per cent (site F) and 66.7 per cent (site D). This is based on OSR data, which has a number of limitations. See Appendix C: Analysis.Similarly, the assessment of change against this characteristic remained at ‘in place but insufficient or incomplete’ for all sites. Community reports and informant interviews consistently highlighting long waiting times for patients at health services appear to support this assessment.As described above the remote Sentinel Sites experienced staff turnover, and this resulted in a lesser change in this area. However, at site F in particular, the recruitment of the RTSHLT addressed a significant need for more health prevention and promotion workers.

Organisations providing a greater range of services

All of the main ICDP funded organisations consulted had expended the range of services

Yes: All of the ICDP funded organisations at the Sentinel Sites were also providing a greater range of services as at 2012 as a result of the

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Common changes expected at evaluation sites at baseline



provided. This included health prevention and promotion programs, transport support, support for GP practices, care coordination and/or secondary service provision.

ICDP, including health prevention and promotion (where RTSHLTs in place), support for patients (largely through ATSIOWs) and GP practices (IHPOs) and where present; care coordination and specialist and allied health services. Factors external to the ICDP including the transition to Medicare Locals and an expansion of service delivery within the AHS at site F also contributed to an expanded range of services being provided; consistent with the evaluation sites which expansions to the range of services were also impacted by factors external to the ICDP.

Increased organisational capacity to cater to community need

Increased organisational capacity was observed within both ICDP funded organisations and other organisations (e.g., GP practices) that were engaged with the ICDP.ICDP investment within funded organisations addressed many previous barriers to community needs being met, for example through provision of transport or new programs to support quit smoking.The changes within other services, such as GPs largely related to improved cultural competency (e.g., treating patients appropriately, collecting Aboriginal and Torres Strait Islander identification information, bulk billing Aboriginal and Torres Strait Islander patients). ICDP staff (IHPOs, ATSIOWs) had a core role in supporting changes in cultural appropriateness within practices. In particular, the IHPO role supported an increased focus on Aboriginal and Torres Strait Islander identification across a number of

Yes^: Improvements to organisational capacity were also observed across the Sentinel Sites as a result of the ICDP addressing barriers to community needs being met. Again increases in capacity were observed within ICDP funded organisations and other organisations, and commonly included: provision of services to address previous gaps – such as transport

(ATSIOWs) and healthy lifestyle programs and activities (RTSHLTs); and

improvements to cultural awareness – changes were observed within many general practices (although this was not across the board) and some of these could be linked to the ICDP; namely the work of IHPOs and the PIP Indigenous Health Incentive. Changes to cultural appropriateness appeared to be most noteworthy where ICDP workers were supported to focus on this area.

Similar to at the evaluation sites; organisations at the Sentinel Sites that embraced the ICDP as a whole initiative (i.e., where ICDP activity, including workers roles and activities, was viewed as a package and embedded into existing programs and activities), rather than taking a measure by measure approach, were able to more effectively embed the ICDP.

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sites. Cultural appropriateness remained an issue; across all sites, there were still some services providing what was deemed by patients to be culturally inappropriate care.ICDP was embraced by organisations with an existing focus on Aboriginal and Torres Strait Islander health, those with capacity to embrace it (e.g., ability to apply for funding, HR systems for recruitment), and later those involved across multiple components which meant a broader range of community needs could be met.

Reduced financial barriers to accessing health care

CtG scripts reduced financial barriers to medicines at all sites. At each of the sites, financial barriers to specialists and/or allied health services were reduced through CCSS and/or USOAP/MSOAP-ICD.

Yes: Similarly to the evaluation sites, at all of the Sentinel Sites with the exception of site E (where community members largely incurred no cost anyway due to S100 RAAHS), CtG scripts reduced financial barriers to medicines. The ICDP CCSS and SOAP measures had less of an impact at the Sentinel Sites where they were present they reduced the financial barriers to accessing secondary care, but they were not present across all Sentinel Sites like they were across all evaluation sites.

Increased access to specialist and allied health services

This was reported across sites, as a result of the CCSS and/or USOAP and MSOAP-ICD programs. Where only CCSS was in place, the limitations on the CCSS program (namely that Care Coordinators can only take on a small number of patients) restricted access to only a segment of the population. The sometimes high proportion of ‘no-shows’ to SOAP clinics most likely led to potential benefits not being realised for some people. Across all sites, ATSIOWs supported

Yes: Where the CCSS and SOAP measures were in place across the Sentinel Sites, they appeared to have a positive impact on access to specialist and allied health services. Again though, the restricted number of CCSS patients and issues with ‘no-shows’ to SOAP clinics most likely limited this for some people.Overall, there were increases in the number of specialists and allied health providers in AHSs across most Sentinel Sites, as noted above. This is likely to have led to increased access but it not necessarily the result of the ICDP.

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patients to access health care across the primary and secondary settings, mostly through provision of transport.

The SSE also found that ATSIOWs played an important role in increasing access to secondary services; both through providing transport and encouraging people to attend appointments.

Increased access to pharmaceuticals

Increased access to pharmaceuticals was reported at all sites, and attributed to the PBS Co-payment measure. This included at the remote site six where the AHS was PIP Indigenous Health Incentive registered.

Yes: Across the Sentinel Sites, the PBS Co-payment measure was commonly observed to have improved access to medications for Aboriginal and Torres Strait Islander patients. At the remote sites, the change observed was different at the other sites:At site E people benefited from access to CtG scripts when they travelled to non-remote areas, but as S100 RAAHS had been operational at this site for some time there was limited change in access to pharmaceuticals; andAt site F, the PBS Co-payment measure was complemented with S100 RAAHS because both initiatives were in place, at this site the ICDP provided people with more choice about where they accessed their pharmaceuticals.The Sentinel Sites found a general positive impact on patients’ capacity to comply with medication plans and maintain continuity of medication, with changes observed across all locations (urban, regional and remote). The change observed was somewhat different to what was observed at the evaluation sites; community feedback suggested some improvements in medicine adherence but not across the board.

Increased access to primary and preventive health care

Increased access to primary and preventive health care was reported at all sites, and resulted from one or a combination of the following ICDP initiatives: RTSHLTs (increased access to preventive information and support), PIP Indigenous Health Incentive, IHPOs

Yes: Increased access to primary and preventive health care was observed across all Sentinel Sites, although the level of change varied, with culturally inappropriate practices limiting access in some locations.The role of the ATSIOW in both AHSs and mainstream sectors commonly appeared to contribute to reducing barriers to accessing

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(increased cultural competency of practices); ATSIOWs and CCSS (building awareness of services, assisting patients to navigate the system, coordinating care, encouraging access to health care); and CtG scripts (people accessing GPs for CtG scripts). Turnover in some sites likely lessened the impact of the change.

health care for community members and encouraging people to engage with health care particularly general practices. Similarly to the evaluation sites, ongoing effects were limited by staffing discontinuity.The RTSHLTs also commonly appeared to contribute to improvements in access to lifestyle modification and healthy lifestyle programs at Sentinel Sites where these teams were in place.

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C.4.3 Variable changes as a result of the ICDP

Table 145: Assessment of the variable changes observed as a result of the ICDP at final stage.Variable changes expected at evaluation sites at baseline

Variable changes observed at evaluation sites at final stage

Relevance to remoteness areas


The perceived value of ICDP investment (based on existing investment at the site)

The perceived need for and value of ICDP services varies across sites to an extent. There were some common needs identified by patients (see above), but there was greater need for the following services/ supports/changes in some sites: access to secondary services (sites

three, four, five and six); increased cultural awareness of

mainstream providers (sites two, three, and five);

knowledge of supports (sites one and two); and

need for care coordination, this was less at site one where a state-funded care coordination program was in place.

There was greater need for knowledge of supports in urban areas, where more services were in the system. Cultural awareness tended to be higher amongst mainstream providers in urban areas.

Yes: Similarly, there was variability in the perceived need for and value placed on ICDP investment across the sites, although at the Sentinel Sights the areas of greater need varied somewhat from the evaluation sites. There was variable need for: prevention programs, based on variable engagement

with and motivation to engage with these programs as observed through the SSE;

access to secondary services, the need for and value of these services dependent on what services were existing (e.g. site A had access to free specialists through the AHS prior to the ICDP, while at site E, only periodic specialist services were accessible through outreach programs operating in the AHS Community Health Centre);

care coordination was less at site B where a state-funded care coordination program was in place;

increased cultural awareness of providers (both AHS and mainstream providers), there was less need for this at some sites such as site E, and more in other sites such as site F.

Uptake of PIP Indigenous Health

The number of patients who were EverIHI as a proportion of the estimated Aboriginal

There were more EverIHI patients (as

Yes: There was also wide variation in the uptake of the PIP Indigenous Health Incentive and PBS co-payment across

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Variable changes expected at evaluation sites at baseline




Incentive and thus participation in CtG scripts

and Torres Strait Islander population with a chronic disease, varied across sites, from 19.15 per cent in site five, to 121.84 per cent in site four.Although there was consistent, high growth in PBS scripts dispensed to EverCtG patients leading up to June 2010 and substantial growth between 2010 and 2011, total numbers and rates of growth varied across the sites.

a proportion of the estimated Aboriginal and Torres Strait Islander population with chronic disease) in regional and remote areas than urban areas consistent with baseline. Site five was the exception with the lowest proportion. Utilisation of CtG scripts was higher in urban areas overall, probably as a function of the population.

the Sentinel Sites: The proportion of Aboriginal and Torres Strait Islander

residents per 100 registered for PIP Indigenous Health Incentive in 2012 varied somewhat; from 21 per cent (site C) to 10 per cent (site A).

Change in PIP Indigenous Health Incentive patient registrations across 2010 to 2012 ranged from an increase of 196.2 per cent (site A) to a reduction of 47.5 per cent (site C).

The number of Aboriginal and Torres Strait Islander people accessing the PBS Co-payment measure per 100 Aboriginal and Torres Strait Islander people aged >15 years320 in 2012 varied from 68.7 with change of 99.7 per cent between 2010 and 2012 (site A); to 19.2 with 131.3 per cent change between 2010 and 2012 (site B); to 51.8 with 1.8 per cent growth between (site C).

There were no registrations in site E due to no eligible PIP Indigenous Health Incentive practice being present at that site, and negligible numbers of people accessing the PBS Co-payment measure.

Receptivity to the ICDP

There were no sites where receptivity was significantly higher than others, rather, receptivity varied within sites e.g., between towns, and between organisations. Receptivity appeared to be

No significant variations by remoteness.

No: The level of receptivity to the ICDP varied distinctly between sites in some cases; for example, there was less receptivity in site F less than other sites. The level of receptivity appeared to be a function of existing commitment to Aboriginal and Torres Strait Islander health

320 Population projected 2006 and 2011 ABS Census data based on the assumption of linear annual growth; ^difference in percentages of total population identified as Aboriginal and Torres Strait Islander.

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a function of existing commitment to Aboriginal and Torres Strait Islander health within general practices, and the capacity of organisations (particularly AHSs and GPs) to undertake required changes such as recruitment of workers, new systems for recall and reminder etc.

(similarly to the evaluation sites) and also based on the level of knowledge of the ICDP amongst service providers, which varied. This is expanded on below.

Where the ICDP will be primarily accessed from

Across the sites, ICDP programs and services were accessed from a range of organisation, both mainstream and Aboriginal and Torres Strait Islander-focused. The variability observed was slightly different to what was predicted. Rather than there being a primary location from which the ICDP was accessed, at final stage, different components of the ICDP were being accessed from different locations and, further, different subgroups of patients were accessing the ICDP from different services. This variability was a function of: what ICDP supports patients required

to meet their needs; their location, patients tended to

access the services and supports in close proximity to them; and

their existing patterns of access (i.e., if a patient usually accessed the AHS,


Yes: Across the Sentinel Sites, ICDP programs and services were accessed from a range of organisations as well, both mainstream and Aboriginal and Torres Strait Islander-focused. In some sites, community members primarily accessed services from one sector (e.g. the site B AHS) while in others it was split between the mainstream and AHS sectors (e.g. site A). As discussed previously, similarly to at the evaluation sites, community members existing patterns of access dictated where they accessed services from and this in turn dictated what ICDP activity they were exposed to.

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they accessed the ICDP services available through this service).

In some sites (sites one, two, five and six) patients reported accessing the ICDP across both AHS and mainstream organisation whereas, in others patients, primarily accessed services from one organisation (sites three and four).

Extent of collaboration between ICDP funded services

All of the sites saw some improvement in collaboration between the AHS and mainstream sectors, although as predicted this varied based on regional contexts, such as the existing relationships between providers and their geographical proximity. The transition to Medicare Locals enhanced collaboration in some sites (e.g., site one) and limited it in others (e.g., site four). In some sites, the transition had little impact in this area (sites three, two and six).


No: The level of improvement in collaboration appeared to vary across the sites, for example: at site B there was only had only minimal change; in

contrast sites A, E and F all saw improvement in areas such as formal and informal mechanisms for collaboration and information sharing; and

at site C, the transition to Medicare Locals facilitated increased coordination and information sharing but overall the level of service coordination remained insufficient.

How well utilised the ICDP will be by patients (based on accessibility)

Utilisation of the ICDP varied across sites, and this appeared to be impacted by a range of factors which also varied across sites: Geographical accessibility, it was

expected that a significant impacting factor would be geographical

Geographical accessibility was more difficult in regional and remote sites, where the ICDP regions (i.e., regional programs and services were

Yes: ICDP utilisation also varied across the Sentinel Sites. Consistently with the evaluation sites, utilisation of the ICDP appeared to be dictated by geographical accessibility, community engagement and motivation, measure models and associated constraints and community needs. In addition, utilisation appeared to be dictated by turnover of positions in remote sites, which affected the momentum of ICDP activity, and community

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accessibility. This was most significant in sites where the ICDP investment was spread over a number of different locations (site four, five and six) than in sites where it was less spread out (sites one and three). In site two, the services were not spread but accessibility was very difficult at baseline due to the population being spread.

Community engagement with health care and motivation to engage with health care, this varied across and within sites with no distinct pattern.

Measure models and associated constraints, in some sites, the models adopted facilitated a greater reach (e.g., the CtG team models in sites one and three).

Community needs, as noted above, the perceived need for and value of ICDP services varied across sites to an extent and this dictated which services were accessed.

expected to cover) were larger and programs were spread over greater distances. Further, the smaller range of services limited geographical accessibility because it led to the requirement to travel to access services.There were no distinct regional variations in the other factors influencing ICDP utilisation.

member and service provider knowledge of the ICDP and its aims, which appeared to be less developed at the Sentinel Sites. This is explored below under ongoing challenges.

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C.5 Health system analysisThis appendix contains three sections: an overview of the Australian health care system; a national policy map; and state and territory policy maps. These have been used to understand the national and jurisdictional context in which the ICDP is being implemented.

C.5.1 Overview of Australian health care systemHealthcare in Australia is provided across a number of settings, which can be classified into either primary, secondary and tertiary. Population or public health services are also available, usually from within the community. Each level of government has varying responsibilities for the funding and provision of healthcare services as the table below shows.

Table 146: Commonwealth and State governments' health care funding responsibilities.Commonwealth government State and territory governmentsMedical services (through the Medicare Benefits Scheme).Pharmaceuticals (through the PBS).Health research.Some public hospital services and public health activities.Private hospitals (through subsidising private health insurance premiums).

Community health services.Patient transport.Most public hospital services and public health activities.

In 2010-11, Australian governments funded approximately 69.1 per cent of health expenditure. Health expenditure was approximately 9.3 per cent of GDP at Final Report.321

C.5.2 Overview of Australian health workforce The Australian health workforce was made up of 548,384 people (2,649 workers per 100,000 people in the population) in 2006, the point at which the most up–to-date data is available. The mix of the medical workforce was changing. For example, between 1997 and 2006, the supply of primary care doctors had decreased, whilst the supply of specialists had increased.322 Although employment in health occupations grew by 23 per cent between 2003 and 2006,

321 AIHW, 2012, Health Expenditure Australia 2010-11, Health and welfare expenditure series no. 47. Cat. no. HWE 56, Australian Institute of Health and Welfare, viewed 14 June, 2013, <http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423003>.322 AIHW, 2009, Health and community services labour force. National health labour force series no. 42. Cat no. HWL 43, Australian Institute of Health and Welfare, viewed 14 June, 2013, <http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442458396>.


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the supply of health workers reduced as remoteness increased. The breakdown of health workers as at 2006323 was: 2,777 health workers per 100,000 in Major Cities (RA1); 2,351 health workers per 100,000 in Regional Australia (RA2, RA3); and 1,603 health workers per 100,000 in Remote (RA4, RA5).Table 147149 below provides an overview of health professionals as at 2012-13.

Table 147: Overview of health professionals as of 2012-13.Type Role Tota

l324

Medical practitioners General practitioners 25,056Hospital non-specialists 9,576Specialists 24475Specialists-in-training 12,491Other clinician 2,382Total 78,833

Nurses and midwives Nurses 271,996

Midwives 14,710Total 286,70

6Dental Dentists 12,734

Dental therapists 1,044Dental hygienists 1,065Oral health therapists 994Dental prosthetists 1,088Total 16,925

Aboriginal and Torres Strait Islander workforce

Medical practitioners 249Nurses 2,043Total 2,292

323 Most recent data available.324 HWA, 2013, Australia’s Health Workforce Series – Health Workforce by Numbers, Health Workforce Australia, viewed 14 June, 2013 <https://www.hwa.gov.au/sites/uploads/Health-Workforce-by-Numbers-FINAL.pdf>.


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C.5.3 Public healthPublic health is defined as ‘the organised response by society to protect and promote health, and to prevent illness, injury and disability. The starting point for identifying public health issues, problems and priorities and for design and implementing interventions, is the population as a whole, or population subgroups.’325 It includes education, lifestyle advice, infection control and risk factor monitoring. Public health activities can occur in a variety of settings, which can include schools, home, workplaces, and health organisations. They are also extremely varied in terms of the workforce, the settings in which they are delivered, their focus and their target group. Public health activities are carried out by all levels of government or other agencies, and priority areas for service delivery can vary as government policy changes. As shown in Table 148150 below, based on government health policy directions there were a number of priority focus areas for public health.

Table 148: Government health policy directions. Population groups Age groupsAboriginal and Torres Strait Islander peoplePeople in rural and remote areasSocioeconomically disadvantaged peopleVeteransPrisonersOverseas born people

Mothers and babiesChildrenYoung peoplePeople over 65

C.5.4 Primary health care

Primary health care is ‘socially appropriate, universally accessible, scientifically sound first level care provided by health services and systems with a suitably trained workforce comprised of multi-disciplinary teams supported by integrated referral systems in a way that; gives priority to those most in need and addresses health inequalities; maximises community and individual self-reliance, participation and control; and involves collaboration and partnership with other sectors to promote public health. Comprehensive primary healthcare includes; promotion, illness prevention, treatment and care of the sick, community development, advocacy and rehabilitation.’326 In Australia, primary health care is provided in a range of settings, most notably GPs, but also community health centres and ACCHOs. Table 149149 below provides an overview of the Australian mainstream primary care system. Information about the AHS sector follows. This is based on the most up to date data available. 325 National Public Health Partnership, 2006, Public Health Classifications Project Phase One: Final Report. Melbourne: NPHP.326 Department of Health and Ageing, 2009, Primary Health Care Reform in Australia: Report to Support Australia’s First National Primary Health Care Strategy. Canberra, Department of Health and Ageing.


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Table 149: Overview of the Australian mainstream primary health care system.Service type Settin

gsFunding Overview of major

services providedWorkforce

Dental Mostly private

Commonwealth and state and territory governments.

Services include preventive and primary dentistry, specialist dental (e.g. orthodontics) and dental aids. Dental services are provided across a broad range of settings including schools, hospitals, private clinics and community health services.

There were 12,734 dentists and 4,191 other dental professional employed across Australia in 2011.327

Allied health Private and public

Medicare is the major funder, with other funding sources including fees to patients (paid by various sources) and other funded support schemes.

Includes: audiologists; chiropractors; dieticians; occupational therapists; optometrists, orthotists; physiotherapists; podiatrists; psychologists; psychotherapists; social workers; speech pathologists; and therapy aides. Physiotherapists make up largest proportion of workforce.

There were approximately 116,800 AHPs employed across Australia in 2008.328

Community health

Mostly public

State and territory governments.

A broad range of programs spanning medical, nursing, allied health, dental and midwifery are provided, targeted across population groups. Also includes community health services.

There are over 4000 community health centres in Australia.

Complementary

Mostly private

Fee for service. Includes: chiropractors; naturopaths; osteopaths;

There were 8,595 complementar

327 HWA, 2013, Australia’s Health workforce series – Health workforce by numbers, Health workforce Australia, viewed 14 June, 2013 <https://www.hwa.gov.au/sites/uploads/Health-Workforce-by-Numbers-FINAL.pdf>.328 AHPA, 2010, Allied health: The facts, Allied Health Professions Australia, viewed 14 June, 2013, <http://www.ahpa.com.au/Portals/0/2010%20Allied%20Health%20Fact%20Sheet.pdf>.


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Service type Settings

Funding Overview of major services provided

Workforce

homeopaths; acupuncturists; and traditional Chinese medicine practitioners.

y health therapists in 2006.329

Ambulance and Royal Flying Doctor Service (RFDS)

Public and private

State and territory governments.

Over 2.9 million incidents were attended in 2009 by ambulances, with the majority being emergency incidents (39 per cent). RFDS attended to 274,000 patient episodes in 2009.

Information not available.

Other organisations

Private Commonwealth government

DoGP, Medicare Locals All 61 Medicare Locals have been established and have commenced operational activities.330

C.5.5 Aboriginal health services sectorThe AHS sector is made up of ACCHOs and some government funded Aboriginal and Torres Strait Islander-specific community health services. The majority of the services provided constitute primary health care, although there is often an element of population or public health and some interface with the secondary and tertiary systems. Table 150150 below provides an overview of the characteristics of ACCHOs and details about their service delivery.

Table 150: Overview of ACCHOs and their service delivery.Characteristics

Overview

Governance ACCHOs are incorporated Aboriginal Organisations that are initiated by a local Aboriginal community, based in a local Aboriginal community, governed by an Aboriginal Board of directors that is elected by the local Aboriginal community, and delivery holistic and culturally appropriate health services to the community, by which it is controlled.

329 Brian Pink, 2008, Australian Social Trends 2008, Australian Bureau of Statistics, viewed 14 June, 2012, <http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/DE5DE30C9CF6E5E3CA25748E00126A25/$File/41020_2008.pdf>.330 Department of Health and Ageing, 2013, Medicare Locals, Department of Health and Ageing, viewed 17 June, 2013, (decommissioned).


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Characteristics

Overview

The National Aboriginal Community Controlled Health Organisation (NACCHO) represents ACCHOs on matters relating to Aboriginal health and wellbeing. At the state and territory level there is an affiliate ACCHO.

Scope In 2013, there were 150 ACCHOs across Australia.331 New South Wales and Queensland had the greatest number of ACCHOs.

Funding ACCHOs are predominantly funded by Commonwealth Government (approximately 72 per cent) and state and territory governments (approximately 27 per cent) grants. The OATSIH provides the highest funding contribution to ACCHOs of all funders.

Service delivery

ACCHOs deliver comprehensive primary health care, including but not limited to general practice, nursing and allied health, and usually some public health programs and initiatives. Many ACCHOs also have some interface with secondary and tertiary care, for example:Many ACCHOs have visiting specialist clinics and services such as drug and alcohol programs; andACCHOs can support the care needs of individuals as they transition to other levels of care and support the provision of secondary care services. This can include providing services that increase access, provide support network services and transport.

C.5.6 Secondary care Secondary care generally refers to specialist medical services. It also includes broader specialised services such as mental health and palliative care. Table 151 provides an overview of the Australian secondary care system.

Table 151: Overview of the Australian secondary care system.Service type Setting Major services and workforceSpecialist medical practitioners

Mostly private, but also some public (i.e. through hospitals, community health).

In 2011, there were 24,475 employed specialists and 12,491 specialists-in-training in Australia.332

Specialised mental health services

Public and private; in residential and non-residential settings.

Includes: psychiatrists, psychologists, community-based mental health services, psychiatric hospitals, psychiatric units within acute hospitals, and residential aged care facilities.

331 NACCHO, 2013, NACCHO | National Aboriginal Community Controlled Health Organisation, National Aboriginal Community Controlled Health Organisation, viewed 17 June, 2013, <http://www.naccho.org.au>.332 HWA, 2013, Australia’s Health workforce series – Health workforce by numbers, Health workforce Australia, viewed 14 June, 2013 <https://www.hwa.gov.au/sites/uploads/Health-Workforce-by-Numbers-FINAL.pdf>.


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Service type Setting Major services and workforceReproductive health Public and private. Includes: contraceptive services,

counselling and information services, early intervention and health promotion services, reproductive support (i.e., IVF) and the medical management of sexual and reproductive health.

Alcohol and other drugs treatment

Public and private; in residential and non-residential settings.

Includes: detoxification and rehabilitation programs, information and education courses, and pharmacotherapy and counselling treatments.

Palliative care Public and private; provided in formal health services or in the home.

Broad range of services provided and workforce utilised with the aim of meeting all of the patient’s needs.

C.5.7 Tertiary care Tertiary care typically refers to services provided by hospitals. Hospitals can vary in size and service provision, but generally, services include emergency departments, outpatient and admitted patient services. In 2010-11, there were 752 public hospitals and 593 private hospitals operating across Australia.333,334 Table 152152 below provides an overview of the Australian tertiary care system.

Table 152: Overview of the Australian secondary care system.Service type Overview of serviceAdmitted care Not available.Emergency department care

In total there were 9.3 million separations (hospital admissions and transfers between types of care) in 2011-12.335

Outpatient care In 2010-11, hospitals provided almost 43 million service episodes of non-admitted patients.336

C.5.8 ICDP workforce investment The ICDP aims to expand the Aboriginal and Torres Strait Islander health workforce through recruitment of additional workers; both Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander workers.

333 ABS, 2012, 4390.0 – Private Hospitals, Australia, 2010-11, Australian Bureau of Statistics, viewed 17 June, 2013, <http://www.abs.gov.au/ausstats/[email protected]/Lookup/BB102E8B1E0AA5EECA257A7100152183?opendocument>.334 AIHW, 2012, Australian hospital statistics 2010-11. Health services series no. 43. Cat. no. HSE 117, Australian Institute of Health and Welfare, viewed 17 June, 2012, <http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421722>.335 ibid.336 ibid.


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http://www.abs.gov.au/ausstats/[email protected]/Lookup/BB102E8B1E0AA5EECA257A7100152183?opendocument


June 2014

The distribution of the workforce across Australia broadly aligns with the distribution of Aboriginal and Torres Strait Islander people across Australia. As at December 2012, organisations across Australia were allocated 528.6 FTE. Compared to June 2011, where organisations were allocated 341.9 FTE. The following tables present a breakdown of the ICDP workforce investment by worker type and remoteness, organisation type and remoteness.

Table 153: ICDP workforce role (FTE) by remoteness at 31 December 2012 and 31 March 2013 for ATSIOW and IHPO.337

Role Major Cities (RA1)

Inner Regional (RA2)

Outer Regional (RA3)

Remote (RA4)

Very Remote (RA5)

Total

Healthy Lifestyle Worker

20.0 9.0 16.0 6 3 54

Regional Tobacco Coordinator

10.0 6.0 10.0 6 4 36

Tobacco Action Worker

19.0 12.0 17.0 8 8 64

Care Coordinator 37.4 30.1 23.1 11.1 1 102.7Additional Health Staff

1.0 0.7 9.2 3.4 2.7 17

ATSIOW 49.6 42.0 14.1 11 6 124.7Practice Manager 6.0 7.0 9.5 3.6 2 28.1IHPO 43.9 26.7 13.8 2 1.5 87.8Total 186.9 133.5 112.7 51.1 28.2 514.

3Proportion of total FTE

36.3% 26.0% 21.9% 9.9% 5.5% 100%

337 Workforce data 2009-13. Provided to KPMG by the former Department of Health and Ageing. Note: FTE figures for June 2010 have been excluded as only figures for ATSIOWs (107) and IHPOs were reported (20); the CC figure for June 2012 from MR2; December 2012 HLW/RTC/TAW figures from A1 A2 Location report Jan 2013.


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June 2014

Table 154: ICDP workforce investment by remoteness.338

Remoteness area Jun-11 Dec-12 Percentage change

Major City 128.9 176.4 36.8%Inner Regional 79.8 121.8 52.6%Outer Regional 77.7 121.6 56.4%Remote 37.5 62.1 65.6%Very Remote 18.0 46.8 160.0%

Total 341.9 528.6 54.6%

Table 155: ICDP workforce investment by organisation type.339

Organisation type

Jun-11

Dec-12

AHS 141.5 264.4DoGP / ML 164.3 190.6NACCHO Affiliate 10.1 19.1SBO 13.0 5.0Other 13.0 49.6Total 341.9 528.6

338 Workforce data 2012, provided to KPMG by the former Department of Health and Ageing. Note data reflects funded ICDP FTE positions (not recruited FTE) at the specified dates. Note ICDP did not fund Care Coordinator positions rather it funded organisations to recruit care coordinators. 339 ibid.


Legislation.

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