Download Lessons from the Lighthouse Project - Vicki Wade

Translating
white
fella
messages
Learnings from the Lighthouse Hospital Project
Vicki
Djuripin
RHDA
Workshop
health
in
Nov
our
Wade
hands
2016
Darwin
© 2011 National Heart Foundation of Australia
2010
2006
2009
2008
2012-2016
Lighthouse hospital project Phase
1&2
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
Conceptual Framework
Care Pathways
patient journey,
variance
Cultural
Competence
safety
and
security
Patient
Family
Community
Workforce
capacity,
training
Governance
leadership, accountability
© 2011 National Heart Foundation of Australia
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.
© 2011 National Heart Foundation of Australia
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.”
© 2011 National Heart Foundation of Australia
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.”
© 2011 National Heart Foundation of Australia
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.”
© 2011 National Heart Foundation of Australia
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.”
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
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.
© 2011 National Heart Foundation of Australia
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”
© 2011 National Heart Foundation of Australia
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…”
© 2011 National Heart Foundation of Australia
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.
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
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.
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
Flinders SA
Currently working on 11 projects
•Aboriginal and Torres Strait Islander Patient Care Guidelines Booklet
–
(first draft completed)
•A Hospital Journey Booklet
–
(first draft completed)
•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
© 2011 National Heart Foundation of Australia
CTSU Elective Waiting List Flow Chart for Flinders Medical Centre (FMC)
Patient listed on
the waiting list as
Patient/client accepted for Cardiac Surgery
Thursday Cardiac Conference Flinders Medical Centre (FMC)
NOT READY
FOR CARE
Northern Territory (NT) referral Letter
On receipt of the Referral letter the FMC CTSU secretary will:
(Category 4)
FMC Admissions will
still need to record if
the patient is a
category 2 or 3
Allocate a date for Cardiac Surgery
3 months in advance
Echocardiogram
Cardiac CNC’s NT
Dental Clearance
<6 months old
TOE - (If required)
Skin Infections and Open Wounds
Breast Feeding
Planning Pregnancy
The patient’s skin should be clear prior to surgery
Treatment of a rash or fungal infections should be
commenced & complete
Cultural Obligations
Past Medical History
One Month prior to the
allocated surgical date
Blood Pathology
Complete Blood
Examination, Urea/Creatine,
Glucose, LFT’s, Calcium,
Magnesium, Phosphate, CK,
Trop T, INR, APTT, HbA1C,
Lipids, Hepatitis C & B.
Iron studies to be added to CBE for
patients with anaemia
Angiogram
(Patients for Valve surgery over the age
of 30 should have an Angiogram)
Carotid Ultrasound
Notify FMC of all open wounds
Complete wound swabs for infections /Treat
As per Addendum
(Within 12 months of surgery)
Current List of Medications
One Month prior to the
allocated surgical date
Including anticoagulants (if applicable)
One Month prior to the allocated
surgical date
All documentation is to be forwarded
to the FMC NT Co-ordinator
All Blood, Urine MC&S and MRO swab results should
be forwarded to the FMC NT Co-coordinator as soon
as the results are available
Urine MC&S
If positive treat with the
appropriate antibiotics
A negative Urine MC&S
is required before Cardiac Valve
Surgery
One month prior
to the allocated surgical date
VRE and MRSA Swabs
The FMC
waiting list
and CTSU
staff are
informed
that the
patient is
READY FOR
CARE
PREPARATION COMPLETE
Confirmed by FMC Co-ordinator
NT to book TRAVEL
Prophylaxis treatment to maintain health
(as required)
Royal Darwin Hospital Alice Springs Hospital
All clear check with The Community Health
Clinic prior to the patient’s flight leaving for
Adelaide
Admission to FMC
Surgery
PREPARATION
INCOMPLETE
Re-schedule a
surgical date 3
months
in advance
FMC CTSU Cardiac
Co-ordinator informs the
CTSU Secretary, who will
notify the waiting list and
admissions that the
patient remains
NOT READY FOR
CARE
(Provide rational)
Cardiac CNC NT
To recommence patient preparation as per
the flow diagram
Echo’s, Angiograms, TOE and Carotid Ultrasound will need to be repeated if delay causes
test age to move outside CTSU guidelines.
© 2011 National Heart Foundation of Australia
© 2011 National Heart Foundation of Australia
GP 7 Day Follow Up Rates
Percentage
100
80
60
% of Patients
Linear (% of Patients)
40
20
0
Pre Intervention
n=74
Intervention
n=67
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
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
© 2011 National Heart Foundation of Australia
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
Percentage
Results
105
100
95
90
85
March 2016 Respecting the
Difference training completions
by %
© 2011 National Heart Foundation of Australia
Tamworth Hospital
Cultural competence
• Environment
• Workforce
Welcome Desk
Ground floor graphic opposite lifts
© 2011 National Heart Foundation of Australia
© 2011 National Heart Foundation of Australia
Heart Foundation
© 2011 National Heart Foundation of Australia