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Building the evidence for service and workforce reform – a case study Institute for Urban Indigenous Health Health Workforce Australia Conference Adelaide Nov 2013. Life expectancy at birth in selected countries.

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slide1

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

Institute for Urban Indigenous Health

Health Workforce Australia Conference Adelaide Nov 2013

slide2

Life expectancy at birth in selected countries

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

causes of excess mortality
Causes of excess mortality

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

burden of disease disability adjusted l ife y ears dalys
Burden of disease – Disability Adjusted Life Years (DALYs)

Vos T, Barker B, Stanley L, Lopez AD 2007. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland.

indigenous health gap dalys by selected causes by remoteness
% Indigenous Health Gap (DALYs) by selected causes – by remoteness

Vos T, Barker B, Stanley L, Lopez AD 2007. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland.

slide6
Maternal and neonatal outcomes for an urban Indigenous population compared with their non-Indigenous counterparts

Sue Kildea, Helen Stapleton, Rebecca Murphy, MachelleeKosiak and Kristen Gibbons. BMC Pregnancy and Childbirth 2013, 13:167  doi:10.1186/1471-2393-13-167

projected indigenous population 2006 2031
Projected Indigenous population 2006 - 2031

Nicholas Biddle: CAEPR Indigenous Population Project 2011 Census Papers No. 14/2013 – Population Projections. http//caepr.anu.edu.au/publications/censuspapers.php

slide9

Nicholas Biddle: CAEPR Indigenous Population Project 2011 Census Papers No. 14/2013 – Population Projections. http//caepr.anu.edu.au/publications/censuspapers.php

what was the evidence in seq
What was the evidence in SEQ?
  • Limited reliable evidence available on the specific needs of urban Aboriginal and Torres Strait Islander people in SEQ
  • Approximately 20-25% of the Aboriginal and Torres Strait Islander population were accessing ATSICCHS clinics; limited evidence available suggested mainstream was not well equipped to be able to respond
  • Focus of Indigenous specific COAG investment by Government on remote communities; focus in urban and regional areas centred on enhancing access to mainstream services
  • Continued growth and dispersal of Indigenous population with ‘shift’ to outer-urban areas – concentration of populations in areas of low socio-economic areas, distant from where ATSICCCHS clinics were originally located
  • Competing interests - including efforts to secure new resources – amongst ATSICCHS located within the SEQ region
  • Uncertainty regarding continued grant funding, with mounting imperative to reduce reliance on grant funding and to increase long-term economic viability of ATSICCHS
  • Complexities of coordinating care across range of different health and related service providers
slide14

Our Vision

The vision of the IUIH is to achieve equitable health outcomes for urban Aboriginal and Torres Strait Islander peoples and to ensure that all Aboriginal and Torres Strait Islander people in the south east Queensland region have access to culturally safe and comprehensive primary health care.

slide15

Institute for Urban Indigenous Health

  • Established as public company limited by guarantee
  • Mixed-Board structure, with:
    • 1 representative from each member ACCHS:
      • ATSICHS Brisbane
      • KambuMedical Centre
      • Yulu-Burri-Ba Health Service
      • Kalwun Health Service
  • PLUS
    • 4 directors appointed for specific skills:
      • Social Marketing/Community Engagement
      • Research /Teaching
      • Finance/Business/Governance
      • Clinical/Public Health
slide16

The IUIH aims to increase health service access and opportunities through provision of support for Aboriginal and Torres Strait Islander health service development and coordination across the SEQ region.

The IUIH also aims to support the effective implementation of the COAG ‘Close the Gap’ initiatives and other strategic developments in the region with emphasis on promoting partnerships and integration with other mainstream health services.

slide17

Responding to the evidence – system and service reform

  • Identify and prioritise areas of SEQ for new ATSICCHS clinics establishment
  • Coordinate a strategic regional approach to community engagement, health promotion and service access
  • Redesign health service systems to improve efficiency and quality, and to increase generation of MBS income
  • On behalf of member ATSICCHS, forge partnerships with mainstream agencies and providers to enhance the response to the needs of Aboriginal and Torres Strait Islander people in SEQ
  • Develop a coordinated regional response to the development of a sustainable Indigenous health workforce
slide18

From evidence to system reform…

  • Identify and prioritise areas of SEQ for new ATSICCHS clinics development
  • Coordinate a strategic regional approach to community engagement, health promotion and service access
  • Redesign health service systems to improve efficiency and quality, and to increase generation of MBS income
  • On behalf of member ATSICCHS, forge partnerships with mainstream agencies and providers to enhance the response to the needs of Aboriginal and Torres Strait Islander people in SEQ
  • Develop a coordinated regional response to the development of a sustainable Indigenous health workforce
slide22

From evidence to system reform…

  • Identify and prioritise areas of SEQ for new ATSICCHS clinics development
  • Coordinate a strategic regional approach to community engagement, health promotion and service access
  • Redesign health service systems to improve efficiency and quality, and to increase generation of MBS income
  • On behalf of member ATSICCHS, forge partnerships with mainstream agencies and providers to enhance the response to the needs of Aboriginal and Torres Strait Islander people in SEQ
  • Develop a coordinated regional response to the development of a sustainable Indigenous health workforce
slide23

Community engagement, health promotion & service access

    • Deadly Choices program
    • Marketing
    • Community Days
    • Incentives – Deadly Choices shirts, competitions, etc.
    • Targeted, localised engagement strategy linking back to clinics – Community Liaison Officers
slide24

From evidence to system reform…

  • Identify and prioritise areas of SEQ for new ATSICCHS clinics development
  • Coordinate a strategic regional approach to community engagement, health promotion and service access
  • Redesign health service systems to improve efficiency and quality, and to increase generation of MBS income
  • On behalf of member ATSICCHS, forge partnerships with mainstream agencies and providers to enhance the response to the needs of Aboriginal and Torres Strait Islander people in SEQ
  • Develop a coordinated regional response to the development of a sustainable Indigenous health workforce
the organised approach
The organised approach…

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

slide27

From evidence to system reform…

  • Identify and prioritise areas of SEQ for new ATSICCHS clinics development
  • Coordinate a strategic regional approach to community engagement, health promotion and service access
  • Redesign health service systems to improve efficiency and quality, and to increase generation of MBS income
  • On behalf of member ATSICCHS, forge partnerships with mainstream agencies and providers to enhance the response to the needs of Aboriginal and Torres Strait Islander people in SEQ
  • Develop a coordinated regional response to the development of a sustainable Indigenous health workforce
slide28

From evidence to system reform…

  • Identify and prioritise areas of SEQ for new ATSICCHS clinics development
  • Coordinate a strategic regional approach to community engagement, health promotion and service access
  • Redesign health service systems to improve efficiency and quality, and to increase generation of MBS income
  • On behalf of member ATSICCHS, forge partnerships with mainstream agencies and providers to enhance the response to the needs of Aboriginal and Torres Strait Islander people in SEQ
  • Develop a coordinated regional response to the development of a sustainable Indigenous health workforce
slide29

Develop a coordinated regional response to the development of a sustainable Indigenous health workforce

  • What workforce do we need to meet demand in SEQ?
    • What type / composition?
    • How much?
  • How do we develop the skills and capacity of the existing workforce to do the job?
  • How do we successfully expand the workforce to keep up with future growth and demand?
  • How do we specifically enhance Aboriginal and Torres Strait Islander employment and career development?
slide30

Develop a coordinated regional response to the development of a sustainable Indigenous health workforce

  • What workforce do we need to meet demand in SEQ?
    • What type / composition?
    • How much?
  • How do we develop the skills and capacity of the existing workforce to do the job?
  • How do we successfully expand the workforce to keep up with future growth and demand?
  • How do we specifically enhance Aboriginal and Torres Strait Islander employment and career development?
slide32

If the full “cycle of care” is completed for everyone who’s eligible, what does a daily workload look like?

  • Assumptions and calculations:
  • 1 GP per 1000 regular Aboriginal and Torres Strait Islander clients…
  • a full cycle of care is completed for all regular clients of the service over a 12 month period
  • At least 30% of total regular client population will be eligible and benefit from a GPMP /TCA (this is conservative)
  • 50% of nurse follow up visits after 715 and 100% nurse follow up visits after GPMP/TCA are captured in a 12 month cycle
  • 2 AHW allied health items after a 715 and 1 of these items after a GPMP /TCA is claimed in a 12 month cycle
  • Remaining GP time in the day is taken up with mostly mid-range consultations – around 20 mins duration
slide36

1x GP

  • 1x Practice Manager
  • 1 x Community Liaison Officer
  • 1 x Driver
  • 1.5 - 2 x Receptionists
  • 1 x Aboriginal Health Worker
  • 1 x Clinic Nurse
  • 1 x Chronic Disease Nurse
slide37

Key principles

Everyone is critical, no-one is spare and everyone will be missed if they’re absent – so also need multi-skilled workforce

Everyone is used to their license

Health professionals other than GPs not only to support effective engagement, access and care, but also make a significant (around 25%) contribution to generation of MBS revenue through interactions NOT involving contact with GP

Size matters – in this model, begin to lose efficiency once service grows beyond a 2 GP core

slide38

Develop a coordinated regional response to the development of a sustainable Indigenous health workforce

  • What workforce do we need to meet demand in SEQ?
    • What type / composition?
    • How much?
  • How do we develop the skills and capacity of the existing workforce to do the job?
  • How do we successfully expand the workforce to keep up with future growth and demand?
  • How do we specifically enhance Aboriginal and Torres Strait Islander employment and career development?
slide39

Mapped functions to job roles  development of standardised regional position descriptions, avoiding duplication and ensuring all key functions are covered

Focus on skills not qualifications

Training needs – individual assessment and development of training plan

Partnership with training institutions to secure access to industry-specific training for SEQ ATSICCHS workforce

On-the-job training – emphasis on skills transfer (formalised in PDs), mentorship and supervision, interdisciplinary learning

Developing Proper Partnerships – cultural mentor program

slide41

Develop a coordinated regional response to the development of a sustainable Indigenous health workforce

  • What workforce do we need to meet demand in SEQ?
    • What type / composition?
    • How much?
  • How do we develop the skills and capacity of the existing workforce to do the job?
  • How do we successfully expand the workforce to keep up with future growth and demand?
  • How do we specifically enhance Aboriginal and Torres Strait Islander employment and career development?
slide42

A home grown workforce

  • Funding and support from GPET / RTPs to support postgraduate medical training – 0.5 medical educator  expanded GPR placements from 1 historically to 7 in 2013
  • Funding from UQ for a full-time position to support effective undergraduate student placements
  •  Regional capacity to enhance both volume and quality of training experience for both trainees and services
slide45

Develop a coordinated regional response to the development of a sustainable Indigenous health workforce

  • What workforce do we need to meet demand in SEQ?
    • What type / composition?
    • How much?
  • How do we develop the skills and capacity of the existing workforce to do the job?
  • How do we successfully expand the workforce to keep up with future growth and demand?
  • How do we specifically enhance Aboriginal and Torres Strait Islander employment and career development?
slide46

Supporting Aboriginal and Torres Strait Islander training, employment and career development

  • ‘Pipeline” beginning with schools-based traineeships – e.g. in 2013, cert II and Cert III allied health assistant training
  • Cadetships; scholarships – service-funded as well as coordination of funding from other sources
  • Indigenous Youth Sports Program (IYSP)
  • Mentor program – 2 way learning
  • Critical mass
  • In addition to Aboriginal and Torres Strait Islander managers, ATSIHWs and nurses, now also exercise physiologist, speech therapist, oral health therapist, dental assistants, researchers including 2 PhD students, etc.
slide47

Managing system reform and improvement

  • Strong leadership
  • Simultaneous governance reform
  • Role of the IUIH “Spearhead”
  • Clinical governance framework
  • Continuous quality improvement:
  • Research and evaluation
  • Closing the data loop – monthly CQI meetings, regional Lead Clinician Group meetings
  • Motivating change – Team Incentive Plan; Leagues Table
slide51

Collaboration and coordination – a case example

  • Signing of statement of intent – IUIH / Brisbane ATSICHS / MNBML / Metro north HHS
  • 3 new clinics in the last 2 years in Moreton Bay region (8500 population) – already reaching around 3500 clients
  • Workforce – over 80% all staff are Aboriginal and Torres Strait Islander; 2 GPRs; 2 Aboriginal RN trainees; 2 AHW trainees
  • On target with Team Incentive Plan; early measures of clinical performance promising; cost-benefit analysis underway (IUIH-contracted health economist)
  • Subcontracted by MNBML to run CTG program; contracted by MNHHS to deliver Care Connect
  • Oral Health Service:
  • Fixed chair in Deception Bay clinic funded as part of capital establishment (QH)
  • Mobile Van funded by DOHA
  • Dentist and dental assistant – start up funding through Medicare Local (MNBML)
  • Funding from QH for Oral Health Therapist (new Aboriginal graduate with initial supervision from QH OHT undertaking research project)
  • Ongoing operation – Medicare revenue generated through PHC service; vouchers from QH for clients on wait list >5 years, Teen Dental funding