Pathways for Aboriginal and

Torres Strait Islander People

TCP Northern Adelaide Local

Health Network

Date:2013

We acknowledge that the land we meet

on today is the land of the Gadigal

people of the Eora Nation. We pay our

respect to Elders past and present, to

their Ancestors and to other Aboriginal

and Torres Strait Islander people present

today.

Overview

My story

TCP Project

Meeting the needs of older Aboriginal

People

Cultural awareness, choices and

flexibility

Case studies

Evaluation

Background of the Aboriginal

Transition Care Project

SA Health recognised the need to increase the

uptake of TCP within the Aboriginal community

SA Health employed Project Workers to cover

the South, Central, Northern and Country Regions

Project Workers Identified and developed state-

wide TCP Pathways

Explored and developed strategies to address

key issues

The Aboriginal Project Officers bring a strong

understanding of the cultural diversities that exist

within both Country and Metropolitan Aboriginal

communities.

Aboriginal Transition Care Project

Our Vision

The Transition Care Program recognises

the complexity and the unique ageing

process of Aboriginal people. The impact

of co-morbidities in the recovery process

and the importance of their roles in

societal wellbeing of the Aboriginal

community.

We acknowledge the life experiences

of older Aboriginal and Torres Strait

Islander peoples.

Meeting the needs of older

Aboriginal people

There is an ongoing challenge to ensure health

services are responsive to the needs of Aboriginal

and Torres Straight Islander people

Many Aboriginal and Torres Strait Islander

people have a lifespan that is up to 17 years

shorter than other Australians.

Whereas older people in the general population

are considered for TCP when over 65 years. It is

sometimes appropriate to plan and deliver

services of this type to Aboriginal people as young

as 50 years to ensure that they receive equitable

services consistent with their needs.

How the TCP Program has

supported the role as Cultural

Advisor

New Model -2013

The role of Aboriginal and Torres Strait

Islander Cultural Advisor has been

expanded to work with all older people

services in NALHN, recognising that

clients may require something other than

TCP. The role now accommodates this

broader approach.

The service operates with a client centred

perspective, the clients needs are

paramount.

The new Model - 2013

All services now have the ability to seek

consultation with the ATSI Cultural Advisor

and direct client assistance will be

available when required. The ATSI

Cultural Advisor will also provide direct

referrals to each service if appropriate.

In order to facilitate this new collaboration

the ATSI Cultural Advisor will seek

consultation with key personnel

within each team to discuss the

activity parameters and protocols

for best practice

Sharing of information and

knowledge with nursing,allied

health personnel, the wider

hospital system, Aboriginal and

main stream services

ATSI TCP Cultural Advisor Pathway

ATSI person admitted to Hospital

ATSI TCP Cultural Advisor notified via email

ATSI TCP Cultural Advisor visits client &

Assesses care needs

Suitable for TCP Not suitable for TCP

TCP referral completed

Continued ATSI TCP Cultural Advisor support

Referred to support services

Planned discharge including referral to support services

ATSI TCP Cultural Advisor contacted about potential hospitalisation

Evaluation

Northern Adelaide Local Health

Networks “YARN – UPS”

Informal information sharing about the

Transition Care Program to:

Elders, Aboriginal Health Service Aged

Care Providers, Community Forums

‘Nunga Grapevine

TCP- Contributing to CTG –

Close The Gap – Aboriginal

health equality

TCP encourages the interrelationships

and values the networking between

services.

Aboriginal and mainstream services

working collaboratively together for the

best outcome of the client

TCP recognizes the gap in life

expectancy, hence the age for ATSI

TCP is 50yrs, where as mainstream is

65 yrs.

Challenges

Identification

Lack of culturally appropriate

resources

Lack of knowledge

Relationships/Communication

Networking

Case Study 1- TCP Northern

Adelaide Local Health Network

57 year old Aboriginal man

3 hospital admissions in 4 months

Complex chronic disease and co-morbidities

Reluctant to accept services

Multiple hospital visits prior to TCP uptake

Case study -1

TCP information was left for the client

to read and or share with family

The client gained trust, felt worthy and

did end up accepting a community TCP

which led to a CACP in discharge

Finally the clients health also improved

extensively, due to accessing the

appropriate services

Case Study -2

77 year old Aboriginal Lady

Admitted to hospital due to a fractured

neck of femur

Hospital stay consisted of over a month

Patient was then transferred to a

rehabilitation program with in a different

Hospital

Patient made very good progress

Patient was discharged home onto

RITH and then TCP

Case Study 2

A comprehensive TCP program was set

up and services continued in her home

for 10 weeks

Regular Case Management/advocacy

meeting were attended

Regular Family meetings held

All networks worked collaboratively

Client now lives independently in her

home, and has made many new friends

during her journey

MY role as Cultural Advisor

Monthly reports

Recording

Data collection

Consultation protocols

Referral processes

Cultural advocacy

Meetings and Education sessions

Multi D liaison

Service needs

Accessing Clients

Questions?