ACHSE Broadcast 21 August 2002: Managing for Indigenous health outcomes

ACHSE BroadcastACHSE Broadcast21 August 2002:21 August 2002:

Managing for Indigenous Managing for Indigenous health outcomeshealth outcomes

Robyn McDermottRobyn McDermott

Barbara SchmidtBarbara Schmidt

Terry MehanTerry Mehan

Things are changingThings are changing

• The global health transition and its determinants

• Consequences of epidemic chronic diseases

• The social gradient in risk behaviours and outcomes

• Implications for health services

25

50

%

Communicable diseases, maternal and perinatal

conditions and nutritional deficiencies

Injuries

DALYs, by broad cause group 1990 - 2020in Developing Countries (baseline scenario)

DALY = Disability adjusted life-year

1990

2020

Source: WHO, Evidence, Information and Policy, 2000

Noncommunicableconditions

• Coronary heart disease• Stroke• Diabetes Compl.• Peripheral vascular disease• Several cancers• COPD/emphysema

EndpointsEndpointsIntermediateRisk

Factors/Diseases

•HypertensionHypertension

•DiabetesDiabetes

•ObesityObesity

•Blood LipidsBlood Lipids

BehaviouralBehaviouralRisk FactorsRisk Factors• Tobacco• Nutrition • Alcohol• Physical Activity

BehaviouralBehaviouralRisk FactorsRisk Factors• Tobacco• Nutrition • Alcohol• Physical Activity

Risk Determinants•Age, Sex •Genes

Risk Determinants•Age, Sex •Genes

Socio-economic, Cultural & Environmental

Conditions

Socio-economic, Cultural & Environmental

Conditions

Noncommunicable Diseases: Risk Factors and Endpoints

Burden of disease attributable to the major Burden of disease attributable to the major risk factors in Australia, 1996risk factors in Australia, 1996

(% of total DALYs)(% of total DALYs)Source: Mathers et al. Bull WHO, 2001Source: Mathers et al. Bull WHO, 2001

0

2

4

6

8

10

12

Tob

acco

Phy

sica

lin

acti

vity

Hig

h B

P

Alc

ohol

harm

Obe

sity

Low

F&

V

MalesFemales

Smoking prevalence in Queensland in Smoking prevalence in Queensland in 1998 by SES1998 by SES

Source: Queensland Statewide Health Survey, 1998Source: Queensland Statewide Health Survey, 1998

0

5

1015

20

25

3035

40

45

50

High SES Middle SES Low SES Lowest SES

S e lf r e p o r te d to b a c c o s m o k in gA b o r ig in a l p a r t ic ip a n ts ,

W e ll P e r s o n ’s H e a lth C h e c k , 1 9 9 8 -2 0 0 0

0

10

20

30

40

50

60

70

80

15-24years

25-34Years

35-44years

45-54years

55+ years

FemalesMales

Rate ratios for lung cancerRate ratios for lung cancerRural, remote and Indigenous Rural, remote and Indigenous

communities, Queenslandcommunities, QueenslandSource: HIC Circular No. 54, Feb 2000Source: HIC Circular No. 54, Feb 2000

0

50

100

150

200

250

300

SIR 1982-96 SMR 1982-96

MaleFemale

Mortality inside and outside capital cities Mortality inside and outside capital cities in Australia, 1986 and 1996in Australia, 1986 and 1996All Causes, age standardised rates/100,000All Causes, age standardised rates/100,000

Source: Sexton et al, MJA 2000Source: Sexton et al, MJA 2000

0

100

200

300

400

500

600

700

800

1986 males

1996 males

1986females

1996females

Capital citiesOutside Capitals

CHD Mortality within and outside capital CHD Mortality within and outside capital cities in Australia, 1986 and 1996cities in Australia, 1986 and 1996

Age-standardised rates/100,000Age-standardised rates/100,000Source: Sexton et al, MJA 2000Source: Sexton et al, MJA 2000

0

50

100

150

200

250

1986 males

1996 males

1986females

1996females

Capital citiesOutside capital cities

Proportion of population in each SEIFA quintile,Proportion of population in each SEIFA quintile,Northern Zone and QueenslandNorthern Zone and Queensland

Source: 1996 CensusSource: 1996 Census

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4 Q5

Non-Indigenous QLDNon-Indigenous NZIndigenous QLDIndigenous NZ

Food Availability- The Healthy Food Access Basket

study (May/Apr, 2000)

The HFAB study looked at market items in three baskets. These were:

• Fruit and Vegetables basket• Healthy Food Access Basket (pictured left)• Tobacco and Take-away basket

Basket Reference Cost % Cost %Fruit, Vegetables and Legumes in Basket

$106.22 $174.24 164% $162.76 153%

Healthy Food Access Basket

$291.41 $445.11 153% $432.53 148%

Tobacco & Take-away Basket

$23.29 $30.00 129% $27.87 120%

Torres RemoteCape York & Mt Isa Remote

Prevalence of diabetes, Indigenous NQ (WPHC) and Australia (AusDiab),

1999-2000

0

10

20

30

40

50

60

15-24 25-34 35-44 45-54 55-64 65+

Non-IndigenousAboriginalTorres Strait Islander

Determinants of incident Determinants of incident Type 2 diabetes in a populationType 2 diabetes in a population

• Overweight/obesity (central obesity)

• Birth weight/weight gain in young adulthood

• Physical inactivity

• Tobacco smoking

• Harmful/hazardous alcohol consumption

• Intra-uterine exposures (glycemia, chronic “stress”, tobacco, low micronutrient density)

• Chronic, systemic stress in the social environment

• Lifetime SES

Male

0

500

1000

1500

2000

2500

3000

3500

1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

Rat

e (p

er 1

00 0

00)

Torres Strait & NPA HSD Qld

North West RA Cape York HSD

Diabetes mellitus- Hospital Separations

Female

0

500

1000

1500

2000

2500

3000

3500

1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

Rat

e (p

er 1

00 0

00)

Torres Strait & NPA HSD Qld

North West RA Cape York HSD

The Chronic Disease Strategy

PREVENTION EARLY DETECTIONMANAGEMENTTobacco

smokingTobaccosmoking

Physical activity & nutrition


Alcohol StrategyAlcohol Strategy

Healthy young women/babiesHealthy young women/babies

Safe SexSafe Sex

ImmunisationImmunisation

Mental HealthMental Health

Annual adult health check


Brief Interventions

Brief Interventions

Children’s health checks


Women’s health checks


Registers and recall systems, and standard treatment protocols for:

- Diabetes

- Cardiovascular disease

- Renal disease

- Chronic respiratory disease

- Sexually transmitted infections

- Mental Health


- Diabetes


- Renal disease



- Mental Health

Environmental Health


How can we improve technical How can we improve technical efficiency in PHC level efficiency in PHC level

management of chronic diseasemanagement of chronic disease?•RegistersRegisters

•Recall systemsRecall systems

•Expert systems (Best practice, Expert systems (Best practice, “EBM”, skilled workforce)“EBM”, skilled workforce)

•Information systems (Wagner, 1996)Information systems (Wagner, 1996)

Prevention:Prevention: Whose job?Whose job?

• Health servicesHealth services• EducationEducation• Community Community

organisationsorganisations• Local governmentLocal government• TransportTransport• Food, tobacco, alcohol Food, tobacco, alcohol

industriesindustries• OthersOthers

ENHANCED MODEL OF ENHANCED MODEL OF PRIMARY HEALTH CAREPRIMARY HEALTH CARE

Focusing the work of primary health care in Indigenous

communities

Enhanced Model of Primary Health Care

Changing the way we do business

• Framework for enhancing services at community level

•Identifies the core activities of PHC in Indigenous Communities

Required inputsNecessary

supportsRequired

outcomes


INPUTS ACTIVITIES OUTPUTS

Health status Program

activity Community

identified needs


INFORMATION EXCHANGE

• Health Indicators

• Services currently provided

• Budget and revenue

• Community issues & needs identified through consultation



Planning in partnership with community What is the burden of disease? What does the evidence say can be

done? Is what we are doing making a difference?


activity Community

identified needs

Shared

understanding of health needs


PARTNERSHIPS

EXAMPLES

All of Government

- Meeting Challenges Making Coices

Regional

- Draft MOU with Apunipima

Community

- Partnership agreement - Yarrabah



Improved health

outcomes



Evidence-based programs The chronic disease strategy Acute care services


activity Community

identified needs

Shared understanding

of health needs


EVIDENCE BASED PROGRAMS

STRATEGIES

• CHRONIC DISEASE STRATEGY

• PUBLIC HEALTH APPROACH

• COLLABORATIE PRACTICE MODEL


PREVENTION EARLY DETECTIONMANAGEMENTTobaccosmokingTobaccosmoking


Physical activity & nutritionAlcohol StrategyAlcohol Strategy

Healthy young

women/babies

Healthy young

women/babiesSafe SexSafe Sex



Annual adult health

check

Annual adult health

check

Brief Intervention

s

Brief Intervention

s






- Diabetes


- Renal disease



- Mental Health


- Diabetes


- Renal disease



- Mental Health





Required Supports Information systems (Ferret) Leadership (management, clinical,

professional) Workforce with the correct skills mix

Improved health

outcomes




Quality standards


activity Community

identified needs

Shared



REQUIRED SUPPORT INFORMATION SYSTEMS

Primary Care Information Systems (Better Health Outcomes Project)

WORKFORCE

Workforce plan developed to:

- Shape the future workforce

- Increase indigenous employment

Innovative workforce strategies to improve recruitment and retentions of all staff





Improved health

outcomes




Quality standards


activity Community

identified needs

Shared


Quality approaches to health care delivery Protocols and care pathways in primary

health care centres Recall and patient management systems

Increased Indigenous employment


QUALITY APPROACHES

PRIMARY CLINICAL CARE MANUAL

CHRONIC DISEASE MANAGEMENT PROTOCOLS

STANDARD HRM PRACTICES

DEVELOPMENT OF QUALITY STANDARDS FOR PRIMARY HEALTH CARE CENTRES





Improved health

outcomes




Quality standards


activity Community

identified needs

Shared


Quality approaches to health care delivery Protocols and care pathways in primary

health care centres Recall and patient management systems

Training Recruitment Workforce Management Indigenous workforce development

Increased Indigenous employment

Sustainable quality

workforce

KEY CHALLENGESKEY CHALLENGESCHANGE MANAGEMENT

• Culture of health service providers and the community• Aligning the organisation to business objectivesZonal•Clearing House for Indigenous Rural and Remote ProjectsDistrict•Changing organisational structures to increase the focus and management of primary health care services

COMMUNICATION• Communication plan

CHANGE MANAGEMENTCHANGE MANAGEMENT

CHANGE MANAGEMENT CHANGE MANAGEMENT

WHY CHANGE

•Health differentials are unacceptable

•Evidence suggests there is a better way


COMPETENCIES FOR MANAGING CHANGE

•Technical apects

•People apsects


TECHNICAL

•Evidenced based Programs

•Information systems•Right workforce mix

PEOPLE

•Ownership•Responsibility

•Shared understanding•Leadership

•Right workforce mix•Increased Indigenous

employment

SUSTAINABLE SOLUTIONS SUSTAINABLE SOLUTIONS

REQUIRES

• Community to understand the problems, own the solutions and take responsibility for the solutions

• The solution to be defined in the community context and not the provider context.

• True partnerships to support capacity development.


PREVENTION EARLY DETECTION MANAGEMENT

TobaccosmokingTobaccosmoking



Alcohol StrategyAlcohol Strategy

Healthy young women/babiesHealthy young women/babies

Safe SexSafe Sex





Brief Interventions

Brief Interventions






- Diabetes


- Renal disease



- Mental Health


- Diabetes


- Renal disease



- Mental Health



THE WAY FORWARDTHE WAY FORWARD

•EMPHC and CDS deal with technical issues

•Need to get the people side right

Strategy implementation requires checklist oftechnical and people aspects to be addressed.

ACHSE BroadcastACHSE Broadcast21 August 2002:21 August 2002:

Managing for Indigenous Managing for Indigenous health outcomeshealth outcomes

Robyn McDermottRobyn McDermott

Barbara SchmidtBarbara Schmidt

Terry MehanTerry Mehan

ACHSE Broadcast 21 August 2002: Managing for Indigenous health outcomes

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Transcript of ACHSE Broadcast 21 August 2002: Managing for Indigenous health outcomes