"You Can't Work with My People If You Don't Know How to": Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease.

Ilse Blignault,Bin Jalaludin,George Bloomfield,Liz Norsa,Raylene Blackburn,Nathan Jones,Karen Beetson

doi:10.3390/ijerph18147233

Abstract

Indigenous Australians experience significantly poorer health compared to other Australians, with chronic disease contributing to two-thirds of the health gap. We report on an evaluation of an innovative model that leverages mainstream and Aboriginal health resources to enable safe, supported transfer of care for Aboriginal adults with chronic conditions leaving hospital. The multisite evaluation was Aboriginal-led and underpinned by the principles of self-determination and equity and Indigenous research protocols. The qualitative study documented processes and captured service user and provider experiences. We found benefits for patients and their families, the hospital and the health system. The new model enhanced the patient journey and trust in the health service and was a source of staff satisfaction. Challenges included staff availability, patient identification and complexity and the broader issue of cultural safety. Critical success factors included strong governance with joint cultural and clinical leadership and enduring relationships and partnerships at the service delivery, organisation and system levels. A holistic model of care, bringing together cultural and clinical expertise and partnering with Indigenous community organisations, can enhance care coordination and safety across the hospital–community interface. It is important to consider context as well as specific program elements in design, implementation and evaluation.

Highlights

Australia’s Indigenous peoples comprise two distinct and diverse cultural groups: Aboriginal and Torres Strait Islander peoples
Two patient interviews were conducted in the Aboriginal patient and family room Campbelltown Hospital
[Aboriginal chronic care] works best when we look at things holistically and when we’re looking at absolutely everything—the psychosocial issues, the social determinants, where people are storing their medication, food—absolutely everything . . . Aboriginal Transfer of Care (ATOC) really brings those conversations to light and if those conversations come to light very early, means we’re looking at things holistically. (P22, Community-based service manager)

Summary

Introduction

Australia’s Indigenous peoples comprise two distinct and diverse cultural groups: Aboriginal and Torres Strait Islander peoples. Their diversity is exemplified by over 250 language groups across the continent and islands [1]. Aboriginal people are believed to have lived in Australia for over 65,000 years and have the world’s oldest continuing culture. Their deep connections to country, family and community have remained strong despite the impact of colonisation on individual and collective health and wellbeing [1,2]. Aboriginal and Torres Strait Islander Australians experience significantly poorer health and wellbeing across the lifespan compared to other

Methods

Discussion

Conclusion