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Problems, Solutions and Actions: Addressing Barriers in Acute Hospital Care for Indigenous Australians and New Zealanders
ORIGINAL ARTICLE
Original Article
Problems, Solutions and Actions: Addressing Barriers in Acute Hospital Care for Indigenous Australians and New Zealanders Patricia M. Davidson a,b,∗ , Andrew MacIsaac c , James Cameron d , Richmond Jeremy e,d , Leo Mahar f,d and Ian Anderson g,h a University of Technology Sydney & St Vincent’s Hospital Sydney, Australia Chair Cardiovascular Nursing Council, Cardiac Society of Australia and New Zealand, Australia c St Vincent’s Hospital Melbourne and University of Melbourne, Australia d Cardiac Society of Australia and New Zealand, Australia e Royal Prince Alfred Hospital and University of Sydney, Australia f Royal Adelaide Hospital, Australia g Foundation Chair of Indigenous Health, Australia Murrup Barak Melbourne Institute for Indigenous Development, University of Melbourne, Australia
b
h
The burden of cardiovascular disease for Indigenous people in Australia and New Zealand is high and reflects the failings of our health care system to meet their needs. Improving the hospital care for Indigenous people is critical in improving health outcomes. This paper provides the results from a facilitated discussion on the disparities in acute hospital care and workforce issues. The workshop was held in Alice Springs, Australia at the second Cardiac Society of Australia and New Zealand (CSANZ) Indigenous Cardiovascular Health Conference. Critical issues to be addressed include: addressing systemic racism; reconfiguring models of care to address the needs of Indigenous people; cultural competence training for all health professionals; increasing participation of Indigenous people in the health workforce; improving information systems and facilitating communication across the health care sector and with Indigenous communities. (Heart, Lung and Circulation 2012;21:639–643) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. Keywords. Indigenous leadership; Workforce capacity and community engagement
Introduction
I
ndigenous Australians are 1.3 times as likely to have cardiovascular disease (CVD) as non-Indigenous Australians and are 3 times more likely to die as a result of their condition [1]. A similar burden of disease is documented in Moari people in New Zealand [2]. The reasons for this health differential are complex and multifaceted and can be attributed to patient, provider and system factors [3]. Although socioeconomic disadvantage is a commonly cited reason for health disparities, given that Indigenous Australians remain at a higher absolute risk than their non-Indigenous peers of the same age and socioeconomic status group, this suggests that there are other factors that must be taken in consideration [4]. Available online 12 September 2012
∗ Corresponding author at: University of Technology Sydney & St Vincent’s Hospital Sydney, Australia. Tel.: +61 2 9514 4822; fax: +61 2 9514 4835. E-mail address: [email protected] (P.M. Davidson).
Entrenched social and health disparities contribute to an increased risk factor burden for CVD [5]. Further difficulties in access and the lack of cultural appropriateness of many health care services mean that Indigenous Australian access services later and with high morbidity [6,1]. Indigenous patients often do not seek help until the advanced stages of illness and hence mortality is high. For cardiovascular care and the management of acute coronary syndromes this is of particular importance because of the time dependent efficacy of revascularisation strategies [7]. In a recent multi-level data linkage study undertaken in New South Wales (NSW) Aboriginal patients admitted with an acute myocardial infarction (AMI) were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients but a higher risk of dying within the next year, although this difference did not persist after adjusting for comorbid conditions. Individuals admitted to lower volume, more remote facilities had a higher risk
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.07.005
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Davidson et al. Problems, Solutions and Actions
of adverse events regardless of Aboriginality [8]. Data from the Australian Institute of Health and Welfare reports more than twice the in-hospital death rate from coronary heart disease (CHD); a 40% lower rate of being investigated by angiography, a 40% lower rate of percutaneous coronary intervention and a 20% lower rate of coronary bypass surgery [9]. These data underscore the importance of investigating barriers to care This paper provides the results from a facilitated discussion on the disparities in acute hospital care and workforce issues. The workshop was held in Alice Springs, Australia at the second Cardiac Society of Australia and New Zealand (CSANZ) Indigenous Cardiovascular Health Conference. The aim of this conference was to provide a platform for combining political, social and medical expertise to address the significant life expectancy gap between Indigenous and non-Indigenous peoples in Australia and New Zealand. The CSANZ has embarked on an impressive body of work to address health disparities for Aboriginal people [10]. Workshop participants represented a range of health professionals including Aboriginal health workers (AHWs), physicians, nurses and allied health professionals. Participants were predominately from Australia therefore the discussion focussed on mainly issues central to Australian acute care but are likely relevant to other settings providing services to Indigenous people. This paper will be organised around three central themes, problems, solutions and actions which were the focus of a facilitated discussion.
Problems
Heart, Lung and Circulation 2012;21:639–643
individuals’ needs, involving them in decisions of care and to meaningfully make them the focus of care. It was commonly agreed that often in the busy culture of hospitals we don’t take the time to stop, listen and act on individual’s needs. Participants also recognised that alienating environments contribute to reluctance to attend hospitals.
Environmental Issues Not only do Indigenous Australians have to commonly travel long distances to receive health care once they get there, hospital environments can appear highly authoritative and the absence of Aboriginal people can mean that hospitals are not-welcoming. This is particularly the case for people from regional and remote areas where there is an intense bond with country [13].
Discharged Against Medical Advice Feeling alienated, marginalised or needing to return back to country for family responsibilities or to seek support were recognised as reasons why Indigenous people discharged themselves against medical advice. Whilst hospitals are not always welcoming or comforting places for Indigenous people, there are other issues at hand as to why Indigenous patients don’t stay, or are discharged against medical advice [14]. Alcohol and tobacco were given as examples of being a big predictor of discharge against medical advice. In such stressful situations it is much easier to leave than to stay and address issues of addiction in addition to their ill health. Having an AHW readily accessible has been found to be highly acceptable to Aboriginal people [15].
Although the literature is replete with barriers to care for Indigenous people, the solutions are less apparent in the literature [11,12]. Through identifying barriers and working with Aboriginal communities, the CSANZ hopes to set an agenda and provide a voice to advocate for a reduction in health care inequalities. Discussants recognised that many barriers to care are germane to all Australians, but the challenges are most highly accentuated in Indigenous Australians who suffer the greatest social, economic and health disadvantage.
Low Numbers of Aboriginal Health Workers
Failing to Provide Person Centred Care
Good data and information management systems are needed to ensure outcomes whether negative or positive are reported appropriately. In addition culturally appropriate identification of Aboriginality is essential to collect accurate and comprehensive data on health service utilisation, and morbidity and mortality [16]. Strategies to reform information management systems must be pursued and such strategies must be implemented with sincere collaboration and engagement with Indigenous people.
Although the position of person centred care is common to many organisational mission and vision statements, enactment of these position are often questionable. Commonly values are highly aspirational and often patient’s needs aren’t the focus of our care. Although participants were highly supportive of personalised care they noted numerous barriers, many of which they considered were beyond their control to address. Constraints such as workforce, equipment and bed shortages precluded tailoring and targeting care for individuals. Discussion during the workshop focused on the importance of person centred care for Indigenous patients. This involved recognising the Indigenous world view, and the importance of family, community and country. Incorporating these approaches to care involve identifying
Unanimously all workshop participants agreed that the AHWs and Aboriginal Liaison Officers (ALOs) were pivotal to improving acute care management of people with CVD. Issues regarding role burden, confusion and lack of career prospects were discussed. The importance of providing support, adequately renumerating and addressing recruitment and retention strategies were noted.
Absence of Data Monitoring Mechanisms
Lack of Continuity of Care and Communication An important factor to improve health outcomes was creating improved efficiencies and communications across health care settings and communities [17]. The challenges of communication from hospitals to community and primary care settings were noted. However, with good will
and innovative systems, improvement in communication can likely be achieved.
Endemic Health Disparities Systemic racism exists with Australia and New Zealand and threatens access to areas such as education, employment, health and housing [18–20]. This endemic racism can be a determinant of poorer health [21]. Although some participants stated that their hospital had reconciliation plans in place, or there were plans to implement such a policy, such processes must not be ad hoc or tokenistic, and should be implemented nationwide. In addition it was noted that individuals and organisations should be aware of racism and sanction discriminatory conduct appropriately. Cultural competence training was underscored as being important in improving patient centred care, however one-off approaches are likely to have little effect. The participants discussed that cultural competency trainings should occur regularly and the issues discussed must be implemented into clinical practice.
Solutions The far-reaching agenda of Close the Gap and Council of Australian Government initiatives were noted and the need for the CSANZ to develop strategic and focussed solutions within the remit of resources and sphere of influence.
Addressing Cultural Barriers and Systems Issues Cultural competence is critical to making gains in Indigenous cardiovascular health, and all health workers must have these skills. Not only to health care workers need to be culturally competent but all hospital personnel including administrative staff. Workshop participants discussed the importance of front desk staff being sensitive to the needs of Indigenous patients and their families, as this is the first point of contact into the healthcare system for many [22]. While there are numerous cultural competencies training programs [23], often they are not suited for everyone, they are ad hoc or superficial and do not involve ongoing monitoring and surveillance [22]. The participants discussed the observation that often the best cultural competence training is walking a mile in another person’s shoes. So models such as the acute care workers going to the Aboriginal Medical Services (AMSs) and the AHW’s coming into the hospital settings has proven to be important and very fruitful [24]. This kind of program also fosters long term partnerships between the community and the hospital.
Stress, Racism, Dispossession Successful chronic disease care requires community engagement, utilising local knowledge, strong leadership, effective communication at all levels, shared responsibilities and sustainable resources [16]. Cardiac rehabilitation programs must therefore form networks and partnerships with local communities and AHWs. Successful cardiovascular programs were discussed where links have been
Davidson et al. Problems, Solutions and Actions
641
established with AMSs and local clinical networks. A participant stated that they sent nurses into the AMS and received AHW in their cardiac catheter laboratories, both received skills and experiences that they could bring back into their own workplace. Success stories shared by participants involved community buy-in and engagement, nurse led initiatives and empowerment of both Indigenous patients and Indigenous health workers. The challenges of overseas trained doctors and nurses were also discussed, particularly in relation to rural and remote hospitals [25]. It was emphasised that they require orientation to the unique needs of Aboriginal people and training in cultural competence.
Expanding the Indigenous Workforce: Medicine, Nursing and Allied Health Indigenous health professionals are critical to ensuring the health of Indigenous people in Australia and New Zealand. Indigenous health workers are a key link between hospitals and the community, providing comfort and culturally appropriate information. Participants described that AHWs are key to preventing discharges against medical advice. Aboriginal Health Workers also act as ‘cultural mentors’ to non-Indigenous staff [26], extending their capabilities in providing culturally competent care. However these roles are often short term contract roles, with limited support and professional recognition or value. Although evolving regulatory environments for AHWs may help to articulate career pathways [27]. Discussion also focussed on the AHW role, in that there is a lack of recognition and lack of career progression. In many hospitals AHW’s are not utilised and have no seniority within the acute care setting. Aboriginal Health Workers are also over-worked with the work day extending well beyond the hours of nine to five. There is also role blurring between AHWs and ALOs; greater clarification between these roles must occur. Participants believed that both of these positions are important within the acute care setting. Others commented that AHWs are trained for the primary health care setting and therefore do not feel comfortable in the hospital sector. It was suggested that AHW training be expanded and incorporate acute care. Associated closely with this is the fact that many, if not most, hospitals are not a particularly welcoming places for Indigenous people; this not only includes patients but Indigenous health workers. Indigenous nurses also play a crucial role in improving acute care for Indigenous people and strengthening the Indigenous workforce [28]. For an increase in Indigenous nurses changes need to occur to the tertiary sector to ensure that Indigenous people are enrolling in nursing and secondly that they complete their degree. Universities can be very alienating for Indigenous students and the provision of mentorship and support is important.
Actions The group acknowledged the progress of the CSANZ over recent years and a number of strategic initiatives
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were summarised. Examples of such initiatives included exploration of outreach programs and institution of scholarships for Indigenous health professionals. The participants concluded that it is critical that the CSANZ alongside the Royal Australasian College of Physicians, and equivalent peak nursing and allied health bodies in Australia and New Zealand, make a clear stand on the importance of Indigenous health. Reducing health disparities should be integral to cardiovascular care; it should not just be the domain of a small number of interested and passionate people but should be core business for everybody. Participants also agreed that the CSANZ should leverage its political influence to advocate for Indigenous health issues.
Heart, Lung and Circulation 2012;21:639–643
Telehealth
Participants considered an important strategy of the CSANZ is in achieving the national procedure registry and outcome registry. Currently, there is not that capacity to monitor performance across institutions and as a consequence it is difficult to target health disparities. In other settings, data driven quality improvement projects have resulted in reducing health disparities.
The use of technology is increasing across Australian communities [31]. The opportunities afforded by telehealth were widely recognised by participants, particularly in view of changes in the Medical Benefits Schedule [32]. Technological solutions could be used for a range of purposes such as case conferencing with patient’s families, and diagnostic and clinical management. Being able to videoconference to discuss treatment conditions through to clinical consults and clinical decision making was discussed as something that could be of value, particularly for those that live in regional, rural or remote areas and don’t want to leave their family or community. This could involve health professionals, patients and their families. Using telehealth technology can enable communication between family members. Telehealth is also a powerful tool to facilitate communication across the health care continuum. This technology can also be used post discharge as participants described the potential benefits of telephone follow-up and health coaching. In spite of available technologies, significant barriers were identified in achieving accurate, appropriate and timely discharge summaries to ensure continuity of care.
Information and Resources
Conclusion
Need for Quality Outcome Data
Participants stated that they believed the CSANZ could play an important role in providing links to sources for cultural competence training. Resources accessible through the HealthInfoNet are readily accessible and likely to be of high utility to individuals working in cardiology settings [29]. CSANZ has the ability to disperse information and resources regarding key issues in Indigenous cardiovascular health to health professionals throughout Australia and New Zealand.
Workforce Reform The importance of workforce development was emphasised as being critical to decreasing health disparities [25]. This was the case across the health care delivery spectrum – from administrative staff, nursing and allied health through to specialist cardiologists. Increasing participation of Aboriginal people in universities is a critical priority [30]. Increasing the knowledge skills and competencies for cardiology health professionals, particularly for cardiology advanced trainees, should be achieved. Rotations through areas with high numbers of Indigenous people and cultural competence training were considered to be of importance.
Aboriginal Health Workers Efforts must also be made to support the specialisation of AHWs in cardiovascular care. Participants decided that something that could be done was to provide assistance and collaboration in developing position descriptions for AHWs and ALOs, these could be matched to national competencies but may assist other employing agencies in determining the skillsets required. Promotion of networks and coordination must also occur so that expertise can be shared across sectors.
Although the widespread challenges of improving Indigenous health outcomes were recognised, participants considered that addressing health disparities in the acute care sector was important and achievable. Although multiple barriers were identified, it was considered that these challenges were not insurmountable and certainly within the remit of the CSANZ to address and develop solutions. In addition to overarching initiatives such as lobbying and advocacy, targeted approaches such as increasing the Indigenous workforce, increasing the numbers and specialisation of AHWs, improving data systems and outcome monitoring, facilitating access to information and cultural competency training and leveraging the opportunities afforded by telehealth are important initiatives and improving health outcomes for Indigenous Australians.
Acknowledgements The authors would like to thank the workshop participants and their collaboration in deriving these recommendations.
References [1] Australian Institute of Health and Welfare. Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004–05. Canberra: AIHW; 2008. [2] Cameron VA, Faatoese AF, Gillies MW, Robertson PJ, Huria TM, Doughty RN. A cohort study comparing cardiovascu¯ ¯ ¯ lar risk factors in rural Maori, urban Maori and non-Maori communities in New Zealand. Br Med J 2012:2, open. [3] Brown A, Brieger D, Tonkin A, White H, Walsh W, Riddell T, et al. The Cardiac Society Inaugural Cardiovascular Health Conference: conference findings and ways forward. Heart Lung Circ 2010;19:264–8.
[4] Cunningham J. Socioeconomic disparities in self-reported cardiovascular disease for Indigenous and non-Indigenous Australian adults: analysis of national survey data. Popul Health Metrics 2010;8:31. [5] Kritharides L, Brown A, Brieger D, Ridell T, Zeitz C, Jeremy R, et al. Overview and determinants of cardiovascular disease in indigenous populations. Heart Lung Circ 2010;19:337–43. [6] Vos T, Barker B, Begg S, Stanley L, Lopez AD. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. Int J Epidemiol 2009;38:470. [7] Aliprandi-Costa B, Ranasinghe I, Chow V, Kapila S, Juergens C, Devlin G, et al. Management and outcomes of patients with acute coronary syndromes in Australia and New Zealand, 2000–2007. Med J Aust 2011;195:116–21. [8] Randall DA, Jorm LR, Lujic S, O’Loughlin AJ, Churches TR, Haines MM, et al. Mortality after admission for acute myocardial infarction in Aboriginal and non-Aboriginal people in New South Wales, Australia: a multilevel data linkage study. BMC Public Health 2012;12:281. [9] Mathur S, Moon LSL. Aboriginal and Torres Strait Islander people with coronary heart disease: further perspectives on health status and treatment. Canberra ACT: Canberra; 2006. [10] Brown A, Brieger D, Tonkin A, White H, Walsh W, Riddell T, et al. Coronary disease in indigenous populations: summary from the CSANZ indigenous Cardiovascular Health Conference. Heart Lung Circ 2010;19:299–305. [11] Vos T, Barker B, Begg S, Stanley L, Lopez AD. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. Int J Epidemiol 2009;38:470–7. [12] Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Effects of self-reported racial discrimination ¯ and deprivation on Maori health and inequalities in New Zealand: cross-sectional study. Lancet 2006;367:2005–9. [13] Thompson SC, Shahid S, Bessarab D, Durey A, Davidson PM. Not just bricks and mortar: planning hospital cancer services for Aboriginal people. BMC Res Notes 2011;4:62. [14] Durey A, Thompson SC, Wood M. Time to bring down the twin towers in poor Aboriginal hospital care: addressing institutional racism and misunderstandings in communication. Intern Med J 2012;42:17–22. [15] Taylor KP, Thompson SC, Dimer L, Ali M, Wood MM. Exploring the impact of an Aboriginal Health Worker on hospitalised Aboriginal experiences: lessons from cardiology. Aust Health Rev 2009;33:549–57. [16] Liaw ST, Lau P, Pyett P, Furler J, Burchill M, Rowley K, et al. Successful chronic disease care for Aboriginal Australians requires cultural competence. Aust N Z J Public Health 2011;35:238–48. [17] DiGiacomo M, Davidson PM, Taylor KP, Smith JS, Dimer L, Ali M, et al. Health information system linkage and coordination are critical for increasing access to secondary prevention in Aboriginal health: a qualitative study. Qual Primary Care 2010;18:17–26.
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[18] Paradies Y, Harris R, Anderson I. The impact of racism on Indigenous health in Australia and Aotearoa: towards a research agenda. Darwin: Cooperative Research Centre for Aboriginal Health; 2008. Report No. 0734039093. [19] Paradies Y, Cunningham J. Experiences of racism among urban Indigenous Australians: findings from the DRUID study. Ethnic Racial Stud 2009;32:548–73. [20] Ward R, Gorman D. Racism, discrimination and health services to aboriginal people in South West Queensland. Aboriginal Islander Health Worker J 2010;34: 3–5. [21] Priest N, Paradies Y, Stewart P, Luke J. Racism and health among urban Aboriginal young people. BMC Public Health 2011;11:568. [22] DiGiacomo ML, Thompson SC, Smith JS, Taylor KP, Dimer LA, Ali MA, et al. ‘I don’t know why they don’t come’: barriers to participation in cardiac rehabilitation. Aust Health Rev 2010;34:452–7. [23] Farrelly T, Lumby B. A best practice approach to cultural competence training. Aboriginal Islander Health Worker J 2009;33:14–22. [24] Davidson PM, DiGiacomo M, Abbott P, Zecchin R, Heal PE, Mieni L, et al. A partnership model in the development and implementation of a collaborative, cardiovascular education program for Aboriginal Health Workers. Aust Health Rev 2008;32:139–46. [25] Davidson PM, DiGiacomo M, Thompson S, Abbott P, Davison J, Moore L, et al. Health workforce issues and how these impact on Indigenous Australians. J Indigenous Health Issues 2011;14:68–84. [26] Durey A. Reducing racism in Aboriginal health care in Australia: where does cultural education fit? Aust N Z J Public Health 2010;34:S87–92. [27] Abbott P, Gordon E, Davison J. Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition. Contemp Nurse 2007;26:66–73. [28] West R, Usher K, Foster K. Increased numbers of Australian Indigenous nurses would make a significant contribution to ‘closing the gap’ in Indigenous health: what is getting in the way? Contemp Nurse 2010;36:121–30. [29] Translational research and the Australian Indigenous HealthInfoNet – working paper; 2012 [accessed at http:// www.healthinfonet.ecu.edu.au/about/translational research]. [30] Curtis E, Wikaire E, Stokes K, Reid P. Addressing indigenous health workforce inequities: a literature review exploring ‘best’ practice for recruitment into tertiary health programmes. Int J Equity Health 2012;11:13. [31] Patterns of Internet access in Australia, 2006. Australian Bureau of Statistics; 2006, http://www.abs.gov.au/ausstats/ [email protected]/mf/8146.0.55.001 [accessed 29.02.2012]. [32] Smith AC, Armfield NR, Croll J, Gray LC. A review of Medicare expenditure in Australia for psychiatric consultations delivered in person and via videoconference. J Telemed Telecare 2012.
ORIGINAL ARTICLE
Heart, Lung and Circulation 2012;21:639–643
Original Article
Problems, Solutions and Actions: Addressing Barriers in Acute Hospital Care for Indigenous Australians and New Zealanders Patricia M. Davidson a,b,∗ , Andrew MacIsaac c , James Cameron d , Richmond Jeremy e,d , Leo Mahar f,d and Ian Anderson g,h a University of Technology Sydney & St Vincent’s Hospital Sydney, Australia Chair Cardiovascular Nursing Council, Cardiac Society of Australia and New Zealand, Australia c St Vincent’s Hospital Melbourne and University of Melbourne, Australia d Cardiac Society of Australia and New Zealand, Australia e Royal Prince Alfred Hospital and University of Sydney, Australia f Royal Adelaide Hospital, Australia g Foundation Chair of Indigenous Health, Australia Murrup Barak Melbourne Institute for Indigenous Development, University of Melbourne, Australia
b
h
The burden of cardiovascular disease for Indigenous people in Australia and New Zealand is high and reflects the failings of our health care system to meet their needs. Improving the hospital care for Indigenous people is critical in improving health outcomes. This paper provides the results from a facilitated discussion on the disparities in acute hospital care and workforce issues. The workshop was held in Alice Springs, Australia at the second Cardiac Society of Australia and New Zealand (CSANZ) Indigenous Cardiovascular Health Conference. Critical issues to be addressed include: addressing systemic racism; reconfiguring models of care to address the needs of Indigenous people; cultural competence training for all health professionals; increasing participation of Indigenous people in the health workforce; improving information systems and facilitating communication across the health care sector and with Indigenous communities. (Heart, Lung and Circulation 2012;21:639–643) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. Keywords. Indigenous leadership; Workforce capacity and community engagement
Introduction
I
ndigenous Australians are 1.3 times as likely to have cardiovascular disease (CVD) as non-Indigenous Australians and are 3 times more likely to die as a result of their condition [1]. A similar burden of disease is documented in Moari people in New Zealand [2]. The reasons for this health differential are complex and multifaceted and can be attributed to patient, provider and system factors [3]. Although socioeconomic disadvantage is a commonly cited reason for health disparities, given that Indigenous Australians remain at a higher absolute risk than their non-Indigenous peers of the same age and socioeconomic status group, this suggests that there are other factors that must be taken in consideration [4]. Available online 12 September 2012
∗ Corresponding author at: University of Technology Sydney & St Vincent’s Hospital Sydney, Australia. Tel.: +61 2 9514 4822; fax: +61 2 9514 4835. E-mail address: [email protected] (P.M. Davidson).
Entrenched social and health disparities contribute to an increased risk factor burden for CVD [5]. Further difficulties in access and the lack of cultural appropriateness of many health care services mean that Indigenous Australian access services later and with high morbidity [6,1]. Indigenous patients often do not seek help until the advanced stages of illness and hence mortality is high. For cardiovascular care and the management of acute coronary syndromes this is of particular importance because of the time dependent efficacy of revascularisation strategies [7]. In a recent multi-level data linkage study undertaken in New South Wales (NSW) Aboriginal patients admitted with an acute myocardial infarction (AMI) were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients but a higher risk of dying within the next year, although this difference did not persist after adjusting for comorbid conditions. Individuals admitted to lower volume, more remote facilities had a higher risk
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.07.005
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Davidson et al. Problems, Solutions and Actions
of adverse events regardless of Aboriginality [8]. Data from the Australian Institute of Health and Welfare reports more than twice the in-hospital death rate from coronary heart disease (CHD); a 40% lower rate of being investigated by angiography, a 40% lower rate of percutaneous coronary intervention and a 20% lower rate of coronary bypass surgery [9]. These data underscore the importance of investigating barriers to care This paper provides the results from a facilitated discussion on the disparities in acute hospital care and workforce issues. The workshop was held in Alice Springs, Australia at the second Cardiac Society of Australia and New Zealand (CSANZ) Indigenous Cardiovascular Health Conference. The aim of this conference was to provide a platform for combining political, social and medical expertise to address the significant life expectancy gap between Indigenous and non-Indigenous peoples in Australia and New Zealand. The CSANZ has embarked on an impressive body of work to address health disparities for Aboriginal people [10]. Workshop participants represented a range of health professionals including Aboriginal health workers (AHWs), physicians, nurses and allied health professionals. Participants were predominately from Australia therefore the discussion focussed on mainly issues central to Australian acute care but are likely relevant to other settings providing services to Indigenous people. This paper will be organised around three central themes, problems, solutions and actions which were the focus of a facilitated discussion.
Problems
Heart, Lung and Circulation 2012;21:639–643
individuals’ needs, involving them in decisions of care and to meaningfully make them the focus of care. It was commonly agreed that often in the busy culture of hospitals we don’t take the time to stop, listen and act on individual’s needs. Participants also recognised that alienating environments contribute to reluctance to attend hospitals.
Environmental Issues Not only do Indigenous Australians have to commonly travel long distances to receive health care once they get there, hospital environments can appear highly authoritative and the absence of Aboriginal people can mean that hospitals are not-welcoming. This is particularly the case for people from regional and remote areas where there is an intense bond with country [13].
Discharged Against Medical Advice Feeling alienated, marginalised or needing to return back to country for family responsibilities or to seek support were recognised as reasons why Indigenous people discharged themselves against medical advice. Whilst hospitals are not always welcoming or comforting places for Indigenous people, there are other issues at hand as to why Indigenous patients don’t stay, or are discharged against medical advice [14]. Alcohol and tobacco were given as examples of being a big predictor of discharge against medical advice. In such stressful situations it is much easier to leave than to stay and address issues of addiction in addition to their ill health. Having an AHW readily accessible has been found to be highly acceptable to Aboriginal people [15].
Although the literature is replete with barriers to care for Indigenous people, the solutions are less apparent in the literature [11,12]. Through identifying barriers and working with Aboriginal communities, the CSANZ hopes to set an agenda and provide a voice to advocate for a reduction in health care inequalities. Discussants recognised that many barriers to care are germane to all Australians, but the challenges are most highly accentuated in Indigenous Australians who suffer the greatest social, economic and health disadvantage.
Low Numbers of Aboriginal Health Workers
Failing to Provide Person Centred Care
Good data and information management systems are needed to ensure outcomes whether negative or positive are reported appropriately. In addition culturally appropriate identification of Aboriginality is essential to collect accurate and comprehensive data on health service utilisation, and morbidity and mortality [16]. Strategies to reform information management systems must be pursued and such strategies must be implemented with sincere collaboration and engagement with Indigenous people.
Although the position of person centred care is common to many organisational mission and vision statements, enactment of these position are often questionable. Commonly values are highly aspirational and often patient’s needs aren’t the focus of our care. Although participants were highly supportive of personalised care they noted numerous barriers, many of which they considered were beyond their control to address. Constraints such as workforce, equipment and bed shortages precluded tailoring and targeting care for individuals. Discussion during the workshop focused on the importance of person centred care for Indigenous patients. This involved recognising the Indigenous world view, and the importance of family, community and country. Incorporating these approaches to care involve identifying
Unanimously all workshop participants agreed that the AHWs and Aboriginal Liaison Officers (ALOs) were pivotal to improving acute care management of people with CVD. Issues regarding role burden, confusion and lack of career prospects were discussed. The importance of providing support, adequately renumerating and addressing recruitment and retention strategies were noted.
Absence of Data Monitoring Mechanisms
Lack of Continuity of Care and Communication An important factor to improve health outcomes was creating improved efficiencies and communications across health care settings and communities [17]. The challenges of communication from hospitals to community and primary care settings were noted. However, with good will
and innovative systems, improvement in communication can likely be achieved.
Endemic Health Disparities Systemic racism exists with Australia and New Zealand and threatens access to areas such as education, employment, health and housing [18–20]. This endemic racism can be a determinant of poorer health [21]. Although some participants stated that their hospital had reconciliation plans in place, or there were plans to implement such a policy, such processes must not be ad hoc or tokenistic, and should be implemented nationwide. In addition it was noted that individuals and organisations should be aware of racism and sanction discriminatory conduct appropriately. Cultural competence training was underscored as being important in improving patient centred care, however one-off approaches are likely to have little effect. The participants discussed that cultural competency trainings should occur regularly and the issues discussed must be implemented into clinical practice.
Solutions The far-reaching agenda of Close the Gap and Council of Australian Government initiatives were noted and the need for the CSANZ to develop strategic and focussed solutions within the remit of resources and sphere of influence.
Addressing Cultural Barriers and Systems Issues Cultural competence is critical to making gains in Indigenous cardiovascular health, and all health workers must have these skills. Not only to health care workers need to be culturally competent but all hospital personnel including administrative staff. Workshop participants discussed the importance of front desk staff being sensitive to the needs of Indigenous patients and their families, as this is the first point of contact into the healthcare system for many [22]. While there are numerous cultural competencies training programs [23], often they are not suited for everyone, they are ad hoc or superficial and do not involve ongoing monitoring and surveillance [22]. The participants discussed the observation that often the best cultural competence training is walking a mile in another person’s shoes. So models such as the acute care workers going to the Aboriginal Medical Services (AMSs) and the AHW’s coming into the hospital settings has proven to be important and very fruitful [24]. This kind of program also fosters long term partnerships between the community and the hospital.
Stress, Racism, Dispossession Successful chronic disease care requires community engagement, utilising local knowledge, strong leadership, effective communication at all levels, shared responsibilities and sustainable resources [16]. Cardiac rehabilitation programs must therefore form networks and partnerships with local communities and AHWs. Successful cardiovascular programs were discussed where links have been
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established with AMSs and local clinical networks. A participant stated that they sent nurses into the AMS and received AHW in their cardiac catheter laboratories, both received skills and experiences that they could bring back into their own workplace. Success stories shared by participants involved community buy-in and engagement, nurse led initiatives and empowerment of both Indigenous patients and Indigenous health workers. The challenges of overseas trained doctors and nurses were also discussed, particularly in relation to rural and remote hospitals [25]. It was emphasised that they require orientation to the unique needs of Aboriginal people and training in cultural competence.
Expanding the Indigenous Workforce: Medicine, Nursing and Allied Health Indigenous health professionals are critical to ensuring the health of Indigenous people in Australia and New Zealand. Indigenous health workers are a key link between hospitals and the community, providing comfort and culturally appropriate information. Participants described that AHWs are key to preventing discharges against medical advice. Aboriginal Health Workers also act as ‘cultural mentors’ to non-Indigenous staff [26], extending their capabilities in providing culturally competent care. However these roles are often short term contract roles, with limited support and professional recognition or value. Although evolving regulatory environments for AHWs may help to articulate career pathways [27]. Discussion also focussed on the AHW role, in that there is a lack of recognition and lack of career progression. In many hospitals AHW’s are not utilised and have no seniority within the acute care setting. Aboriginal Health Workers are also over-worked with the work day extending well beyond the hours of nine to five. There is also role blurring between AHWs and ALOs; greater clarification between these roles must occur. Participants believed that both of these positions are important within the acute care setting. Others commented that AHWs are trained for the primary health care setting and therefore do not feel comfortable in the hospital sector. It was suggested that AHW training be expanded and incorporate acute care. Associated closely with this is the fact that many, if not most, hospitals are not a particularly welcoming places for Indigenous people; this not only includes patients but Indigenous health workers. Indigenous nurses also play a crucial role in improving acute care for Indigenous people and strengthening the Indigenous workforce [28]. For an increase in Indigenous nurses changes need to occur to the tertiary sector to ensure that Indigenous people are enrolling in nursing and secondly that they complete their degree. Universities can be very alienating for Indigenous students and the provision of mentorship and support is important.
Actions The group acknowledged the progress of the CSANZ over recent years and a number of strategic initiatives
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were summarised. Examples of such initiatives included exploration of outreach programs and institution of scholarships for Indigenous health professionals. The participants concluded that it is critical that the CSANZ alongside the Royal Australasian College of Physicians, and equivalent peak nursing and allied health bodies in Australia and New Zealand, make a clear stand on the importance of Indigenous health. Reducing health disparities should be integral to cardiovascular care; it should not just be the domain of a small number of interested and passionate people but should be core business for everybody. Participants also agreed that the CSANZ should leverage its political influence to advocate for Indigenous health issues.
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Telehealth
Participants considered an important strategy of the CSANZ is in achieving the national procedure registry and outcome registry. Currently, there is not that capacity to monitor performance across institutions and as a consequence it is difficult to target health disparities. In other settings, data driven quality improvement projects have resulted in reducing health disparities.
The use of technology is increasing across Australian communities [31]. The opportunities afforded by telehealth were widely recognised by participants, particularly in view of changes in the Medical Benefits Schedule [32]. Technological solutions could be used for a range of purposes such as case conferencing with patient’s families, and diagnostic and clinical management. Being able to videoconference to discuss treatment conditions through to clinical consults and clinical decision making was discussed as something that could be of value, particularly for those that live in regional, rural or remote areas and don’t want to leave their family or community. This could involve health professionals, patients and their families. Using telehealth technology can enable communication between family members. Telehealth is also a powerful tool to facilitate communication across the health care continuum. This technology can also be used post discharge as participants described the potential benefits of telephone follow-up and health coaching. In spite of available technologies, significant barriers were identified in achieving accurate, appropriate and timely discharge summaries to ensure continuity of care.
Information and Resources
Conclusion
Need for Quality Outcome Data
Participants stated that they believed the CSANZ could play an important role in providing links to sources for cultural competence training. Resources accessible through the HealthInfoNet are readily accessible and likely to be of high utility to individuals working in cardiology settings [29]. CSANZ has the ability to disperse information and resources regarding key issues in Indigenous cardiovascular health to health professionals throughout Australia and New Zealand.
Workforce Reform The importance of workforce development was emphasised as being critical to decreasing health disparities [25]. This was the case across the health care delivery spectrum – from administrative staff, nursing and allied health through to specialist cardiologists. Increasing participation of Aboriginal people in universities is a critical priority [30]. Increasing the knowledge skills and competencies for cardiology health professionals, particularly for cardiology advanced trainees, should be achieved. Rotations through areas with high numbers of Indigenous people and cultural competence training were considered to be of importance.
Aboriginal Health Workers Efforts must also be made to support the specialisation of AHWs in cardiovascular care. Participants decided that something that could be done was to provide assistance and collaboration in developing position descriptions for AHWs and ALOs, these could be matched to national competencies but may assist other employing agencies in determining the skillsets required. Promotion of networks and coordination must also occur so that expertise can be shared across sectors.
Although the widespread challenges of improving Indigenous health outcomes were recognised, participants considered that addressing health disparities in the acute care sector was important and achievable. Although multiple barriers were identified, it was considered that these challenges were not insurmountable and certainly within the remit of the CSANZ to address and develop solutions. In addition to overarching initiatives such as lobbying and advocacy, targeted approaches such as increasing the Indigenous workforce, increasing the numbers and specialisation of AHWs, improving data systems and outcome monitoring, facilitating access to information and cultural competency training and leveraging the opportunities afforded by telehealth are important initiatives and improving health outcomes for Indigenous Australians.
Acknowledgements The authors would like to thank the workshop participants and their collaboration in deriving these recommendations.
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