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Chronic Care for Aboriginal People Raylene Gordon

Chronic Care for Aboriginal People Raylene Gordon. GP NSW Aboriginal Health Workshop 5 th August 2009. Chronic Disease in NSW. We know that …. Aboriginal people are: Twice as likely to be hospitalised for heart disease and stroke 4 to 5 times more likely to be hospitalised for diabetes

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Chronic Care for Aboriginal People Raylene Gordon

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  1. Chronic Care for Aboriginal People Raylene Gordon GP NSW Aboriginal Health Workshop 5th August 2009

  2. Chronic Disease in NSW

  3. We know that…. Aboriginal people are: • Twice as likely to be hospitalised for heart disease and stroke • 4 to 5 times more likely to be hospitalised for diabetes • 3 to 5 times more likely to be hospitalised for chronic respiratory disease

  4. Over representation of Aboriginal people in custody

  5. Aboriginal Population by AHS

  6. Aboriginal Population by Age

  7. Walgan Tilly Project Chronic Care for Aboriginal People (CCAP) • GOALS • Practical steps and real solutions to improving access to chronic disease services. • Building working relationships between Aboriginal and mainstream chronic disease services • Identification and sharing of best practice in meeting the needs of Aboriginal people with chronic disease

  8. From Vascular to Chronic Disease

  9. A new focus on treating the people who have the disease, not the disease itself A holistic approach to health The colours represent the connection to country. The focus is not just on the patient but on the family

  10. Chronic Care for Aboriginal People

  11. Key Performance Indicators

  12. Local AH Solutions …

  13. Identification The standard question to ask is: • Are you of Aboriginal or Torres Strait Islander origin?

  14. ‘Aunty Jeans’ Rehabilitation Program • Rehabilitation v’s Maintenance Program • Recruitment of new participants • Reintroducing QOL tool on entry, 8 weeks and 3-6 months after the service • Recording B/P, BGL,HbA1c,weight/BMI, daily exercise times & results for 6MWT • 6MWT be introduced twice in the program, as baseline and then for review • Communication with GP’s on participants entry and exit from the service

  15. “% of Aboriginal patients with chronic disease followed up within 24-48 hours of discharge from hospital, by any member of the agreed health provider team” 48 Hour Follow up

  16. Clinical Indicators • Exploring Demonstration site for example of collection at AHS level • Develop Clinical Indicators – • HbA1c • Spirometry • Blood pressure • Albumin to Creatinine Ratio

  17. 6 Statewide Solutions … • Model of Care for Aboriginal People • Integration of Aboriginal Health and mainstream Chronic Care • Greater Aboriginal cultural awareness and cultural sensitivity of services • Justice Health linkages • Improved access to primary care • Improved data quality

  18. Development of the framework

  19. Model of Care • Specific to Aboriginal people • Specific to Chronic Disease • Cater for “Circumstantial co morbidities” • Coordinate support across different service systems • Individual, carer and family centered care

  20. Thank You

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