Translating white fella messages Learnings from the Lighthouse Hospital Project Vicki Wade Djuripin health in our hands RHDA Nov 2016 Workshop Darwin

Lighthouse hospital project Phase 2010 2006 2009 2008 2012-2016 Lighthouse hospital project Phase 1 & 2 Catalyst 2006 report – Data from Qld, WA, SA & NT, vic released data in 2009 40% lower rate of investigation by angiography 40% lower rate of angioplasty or stent procedures 20% lower rate of coronary bypass surgery WG/community of interest with reps including cardiologist, academics, bueartracts and key politcitian's and policy people as well as consumers The outcome of this work was the Better Hospital care policy paper. The report identifies 15 broad recommendations for improvements and was used to raise awareness of these issues among governments, hospitals, clinicians and other interested parties, and to provide a basis for them to work together towards solutions that will help to close the gap in Aboriginal and Torres Strait Islander heart health. The Heart Foundation/AHHA report 'Better hospital care for Aboriginal and Torres Strait Islander people experiencing a heart attack' concluded that: - Some good things are happening in some places - More research and better, comprehensive data collection is needed - Addressing hospital disparities is a complex task that will involve the commitment of organisations and individuals in both government and non-government sectors. Phase 2 of this program is a 5 year project to design and implement a lighthouse hospital project over the next 5 years. The concept of a lighthouse hospital involves documentation, sharing and mentorship by exemplary hospitals to allow other institutions to benefit from their knowledge and expertise. This includes collecting case studies of what is currently working! $150,000 for the first year to develop case studies and a comprehensive business case

Phase 2 Lighthouse Project Hospital Evaluation 8 Focus groups 43 one on one interviews Patient interviews Pre and post educational workshop Toolkit evaluated 9 case studies – patient stories Final report Economic analysis

Conceptual Framework Care Pathways patient journey, variance Workforce capacity, training Governance leadership, accountability Cultural Competence safety and security Patient Family Community This feedback also resulted in an update to the model initially proposed and this will form the model for Phase II of the project. The key differences from the model originally proposed are; Patient, family and community became the centre of the model as opposed to the journey. This put the focus on them and their individual requirements and not the ‘standard’ journey they must go through Changing clinical quality improvement to care pathways as the entire aim of Phase 2 will be about quality improvement. This means we also focus on the variance of care from best practice. The additional of competence to the cultural concept Accountability became a subset of governance and leadership instead of management.

Evaluation – phase 2 Toolkit To examine whether the toolkit has improved awareness, knowledge and confidence of hospital staff on providing culturally appropriate care of Aboriginal and Torres Strait Islander patients. To assess whether the toolkit is practical, whether it includes clear and appropriate information. Whether the information is relevant and can be understood and used by hospital staff to improve the health outcomes of Aboriginal and Torres Strait Islander peoples.

KEY FINDINGS – SUGGESTED CHANGES TO THE TOOLKIT Common suggestions and recommendations to improve usability and functionality of the toolkit. Comprehensive introductory session Re-ordering of four domains Some pilot sites reported the need for a more comprehensive orientation to the toolkit and quality improvement methodology. “If we had that introduction to the toolkit at the beginning that would have helped us navigate a bit better.”

KEY FINDINGS – SUGGESTED CHANGES TO THE TOOLKIT Inclusion of real life stories from participating hospitals “Specific examples/case studies of what people can do, should do or should think about.” “You could have a case study of the whole hospital, a case study of an action – such as how did you go about identification of a need.”

KEY FINDINGS – IMPORTANCE OF LIGHTHOUSE Common view across hospitals of the significant need for the Lighthouse project due to a number of issues and barriers facing the health of Aboriginal and Torres Strait Islander peoples. Some of which include: High prevalence of heart disease amongst Aboriginal and Torres Strait Islander peoples. Prejudices experienced by Aboriginal and Torres Strait Islander patients. “It has made us realise that some of our staff have no idea that they are actually racist or their behavior is racist.”

KEY FINDINGS – IMPORTANCE OF LIGHTHOUSE Gaps in awareness and knowledge amongst staff in understanding the needs of Aboriginal and Torres Strait Islander patients. “I definitely think there is a need for it. I think there is a gap in knowledge, not just for nursing staff but for all allied health and medical staff.” The need to improve the care and treatment of Aboriginal and Torres Strait Islander patients, both during their hospital stay and post discharge. “There is a noticeable gap – we notice it when we talk about case presentations– we looked at what’s happened, how we could have improved and especially on discharge, on their journey outside the hospital – how we can prevent readmissions.”

KEY FINDINGS – SHORT TERM IMPACTS Positive changes experienced across each of the hospitals include: Increased awareness and knowledge levels amongst staff of the issues and barriers faced by Aboriginal and Torres Strait Islanders. “Much greater awareness and empathy around Aboriginal and Torres Strait Islander health and their knowledge has grown significantly.” “So really thinking through ok so I now have an Aboriginal patient in front of me – how does my care plan deviate, how does what I do impact on this person, is there something specific that I should be doing. So that’s been quite powerful actually.” Culture as a significant enabler to care

KEY FINDINGS – SHORT TERM IMPACTS Development of relationships with the Aboriginal and Torres Strait Islander community, as well as with community health groups. “We can see doctors/nurses changing behaviour. We can see the better linkages back to the GPs and there’s a hugely improved patient experience. Some of the GPs we have been talking to have been very happy with what we’ve been doing.” “It’s opened up their eyes too about the need to actually engage more with the community around this.

KEY FINDINGS – SHORT TERM IMPACTS Improved relationships and interaction with Aboriginal and Torres Strait Islander patients. “Definitely our environment has changed. The buy in from staff is amazing. The changes that I’ve seen in the staff, have been phenomenal. They ring me if they have an Aboriginal patient, they want to debrief about the patient they’ve had, they want to know whether they’ve done the right thing, or if there is something else they could have done better. So it’s their level of understanding of why it’s important and what they’re doing and the way they treat patients now has had a fairly significant impact in the future”

KEY FINDINGS – BROADER APPLICATION OF THE TOOLKIT Lighthouse toolkit has a broader application within the hospitals than just for patients with Acute Coronary Syndrome. “You can use it across diverse areas. In terms of the work force, the governance, the cultural competence – all those areas (topics) can go across all service areas…..respiratory, diabetes…”

29 Key messages from 9 case studies Cost of Ambulance can be a deterrent of health care. People experience a variety of feelings and emotions during the entire heart attack journey (isolation, frightened, confused neglected) Communication between health care provider and patient is very important for patients overall experience and confidence in the care they are receiving. Having Aboriginal people employed and visible in hospitals can be reassuring to Aboriginal patients. Aboriginal people often view hospitals as sterile unfriendly places that do not align with their culture. Aboriginal Liaison Officers can be a great comfort for Aboriginal people particularly if they are away from home. Confidentiality is seen as a barrier to access. Attendance rates at Cardiac Rehabilitation are much lower for Aboriginal and Torres Strait Islander peoples.

Key messages from 9 case studies Nurses at Aboriginal Community Controlled Health Organisation are vital to help communication between hospitals and communities. Communication out to community organisations is very important for Aboriginal and Torres Strait Islander peoples. Follow up care including discharge medications especially Close the Gap scripts need improving. Cultural competence of a hospital is very important and can prevent patients discharging themselves against medical advice. Communication between transferring hospitals is important for continuity of care. The cost of an ambulance can be a barrier to Aboriginal people accessing care in a timely manner. Follow up is very important in the overall patient journey and can be complicated with hospital transfers from the country to the city

Key messages from case studies Proper communication can prevent a lot of anxiety, confusion and uncertainty about health care provided. Informed consent for medical procedures must come from the right person, to the right person at the right time. Nominating a family member as a spokes person or advocate is common amongst Aboriginal patients, it must be the patient who names this person not the health worker. Post op education can improve chances of recovery emotional and physical. How a person is treated in hospital has direct impact on their care. Discharge Against Medical Advise is an issue with Aboriginal and Torres Strait Islander peoples. Aboriginal and Torres Strait Islander peoples feel safer when they have other Aboriginal and Torres Islander peoples around. Family are important health advocates for Aboriginal and Torres Strait Islander patients

Key messages from case studies Family support is very important for Aboriginal and Torres Strait Islander peoples as health not only affects the physical well-being of the patient, but also refers to the emotional, social and cultural well-being of the whole Community. Attendance rates to Cardiac Rehabilitation for Aboriginal and Torres Strait Islander peoples at CR are much lower. Having familiar staff members and feeling supported is important to care Understanding cultural differences results in a health service being more responsiveness and flexible. Providing health services that are cultural competent can break down barriers. Having a dedicated cultural space or room can put Aboriginal and Torres Strait Islander peoples at ease, connect better with hospital and improve care.

FINAL REPORT EMS CONSULTANTS Key findings what we have learnt Embedding change takes time (12 -18month not long enough) Community engagement and strong relationships are needed to improve access and post discharge care Building a strong network of clinicians Wider application In order to achieve health outcomes there needs to be ongoing investment Economic analysis- reducing DAMA 4.4% - 0.5% can save 15.9 million / annually avoid 1643 a year stopping readmissions

Flinders SA Currently working on 11 projects Aboriginal and Torres Strait Islander Patient Care Guidelines Booklet (first draft completed) A Hospital Journey Booklet Patient Rights and Responsibilities Booklet Top Ten Tips Welcome Package (bag containing toiletries, transport card, map of Adelaide, Journey Booklet, Rights and Responsibilities Booklet, etc.) An electronic Outpatients Form for CTSU NT Waiting List Flowchart and implementation (working for 3 months from time of referral – started March 2016) A CTSU/Cardiology/ICCU Aboriginal Liaison Officer (ALO) or Health Worker Position(s) Increase ALO knowledge of tests and procedures, medical record recording by ALOs. Designing a Culturally appropriate 30 day/6 month follow-up Cultural Awareness/Competency Education Course

CTG medication subsidy scheme The CTG subsidy scheme does not apply in the hospital setting. Very complex confusing process has been used to address this issue. There was no consistency with the process. A submission to trial supplying Aboriginal and Torres Strait Islander patients that are registered with CTG with 7 days free supply of medication was successful. A trail is currently being undertaken by the pharmacy department. 60 patient Cost $24 per patient GP follow up within 7 days Referral to primary health network to assist patient to register for CTG Ongoing evaluation

Key achievements Increased visibility of patient’s Aboriginal identification status. Aboriginal status is visible on nursing handover sheets and other clinician patient lists Consultation with regional referral services: Bairnsdale and Swan Hill Trial of discharge back to home hospital Development and delivery of three training modules on culturally appropriate care for clinicians and clerical staff. Cross cultural training for clinical + clerical, innovative yarning module Separate guidelines for clinical and clerical staff highlighting culturally specific care processes identified through patient journey mapping. To be linked to the training modules

Aboriginal Cardiac Care Working Group (ACCWG) Meets monthly Membership includes an AHLO, nursing staff, Nurse Unit Manager, representative from Quality Unit Aboriginal patient case studies Process of care issues explored and discussed Improvements to systems of care r

Tamworth Hospital Aboriginal Cultural Respect Education Program (CC & W) Target: ED, ICU/CCU, medical ward, cardiac services 4 modules (13 hours): Module 1 NSW Health Aboriginal Culture – Respecting the Difference online training Module 2 Manager Conversation 1 Module 3 Aboriginal Cultural Respect Education workshop (now available monthly) Module 4 Manager Conversation 2 Results

Ground floor graphic opposite lifts Tamworth Hospital Cultural competence Environment Workforce Welcome Desk Ground floor graphic opposite lifts

Heart Foundation