Chronic Care for Aboriginal People Raylene Gordon

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Chronic Care for Aboriginal People Raylene
Gordon

• GP NSW Aboriginal Health Workshop 5th August 2009

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(No Transcript)
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Chronic Disease in NSW
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We know that.

• Aboriginal people are
• Twice as likely to be hospitalised for heart
  disease and stroke
• 4 to 5 times more likely to be hospitalised for
  diabetes
• 3 to 5 times more likely to be hospitalised for
  chronic respiratory disease

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Over representation of Aboriginal people in
custody
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Aboriginal Population by AHS
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Aboriginal Population by Age
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Walgan Tilly Project Chronic Care for Aboriginal
People (CCAP)

• GOALS
• Practical steps and real solutions to improving
  access to chronic disease services.
• Building working relationships between
  Aboriginal and mainstream chronic disease
  services
• Identification and sharing of best practice in
  meeting the needs of Aboriginal people with
  chronic disease

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From Vascular to Chronic Disease
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A holistic approach to health
The colours represent the connection to country.
The focus is not just on the patient but on the
family
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Chronic Care for Aboriginal People
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Key Performance Indicators
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Local AH Solutions
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Identification

• The standard question to ask is
• Are you of Aboriginal or Torres Strait Islander
  origin?

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Aunty Jeans Rehabilitation Program

• Rehabilitation vs Maintenance Program
• Recruitment of new participants
• Reintroducing QOL tool on entry, 8 weeks and 3-6
  months after the service
• Recording B/P, BGL,HbA1c,weight/BMI, daily
  exercise times results for 6MWT
• 6MWT be introduced twice in the program, as
  baseline and then for review
• Communication with GPs on participants entry and
  exit from the service

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48 Hour Follow up

• of Aboriginal patients with chronic disease
  followed up within 24-48 hours of discharge from
  hospital, by any member of the agreed health
  provider team

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Clinical Indicators

• Exploring Demonstration site for example of
  collection at AHS level
• Develop Clinical Indicators
• HbA1c
• Spirometry
• Blood pressure
• Albumin to Creatinine Ratio

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6 Statewide Solutions

• Model of Care for Aboriginal People
• Integration of Aboriginal Health and mainstream
  Chronic Care
• Greater Aboriginal cultural awareness and
  cultural sensitivity of services
• Justice Health linkages
• Improved access to primary care
• Improved data quality

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Development of the framework
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Model of Care

• Specific to Aboriginal people
• Specific to Chronic Disease
• Cater for Circumstantial co morbidities
• Coordinate support across different service
  systems
• Individual, carer and family centered care

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Thank You