Building better systems of care for Aboriginal and Torres Strait Islander people: findings from the Kanyini health systems assessment

Background Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment. Methods Two theories informed the study: (1) ‘candidacy’, which explores “the ways in which people’s eligibility for care is jointly negotiated between individuals and health services”; and (2) kanyini or ‘holding’, a Central Australian philosophy which describes the principle and obligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed. Results Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, and commitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld. Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is ‘tractable’ and ‘navigable’ to its users. Staff also described entrenched patient discrimination in hospitals and the need to expend considerable effort to reinstate care. This suggests that Aboriginal and Torres Strait Islander people are still constructed as ‘non-ideal users’ and are denied from being ‘held’ by hospital staff. Conclusions Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs ‘hold’ their users and enhance their candidacy to health care. Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.


Registered Nurses
Record the number of RNs currently employed within the health service. Record the number of RNs who are indigenous.

Male Aboriginal Health Workers
Record the number of male AHWs currently employed within the health service.

Female Aboriginal Health Workers
Record the number of female AHWs currently employed within the health service.

Allied Health staff
Record the number of Allied Health persons currently employed. List each Allied Health position(s).

Cultural congruence
Cultural Awareness Program Do health service staff undertake cultural awareness training programs when commencing work at the service?

Cultural leave provision
Does the health service have provision for indigenous staff to take cultural leave for funerals etc.?
Use/support of Ngangkari/ tranditonal healing Does the health service use and support the use of Ngangkari/Traditional Healers?

Funded Ngangkari/ traditional healing services
Are Ngangkari/Traditional Healers paid by the health service for consultations?

Separate Men's and Women's space
Does the health service have designated women's/ men's areas within the service?

Quality of care
Routine quality improvement activities conducted Does the health service have a systematic Quality Improvement (QI) process in place? Can you describe the QI initiatives that are in place?

Dedicated quality improvement staff
Does the health service have an identified position responsible for developing, maintaining and coordinating Quality Improvement processes within the health service?

Guideline training provided to staff
Does the health service provide training to staff, in the use of these guidelines? Can you describe what the training consists of?

Models of care
Outreach clinics Does the health service provide outreach primary care services? Can you describe these services?
Chronic disease case management Does the health service use a case management model for clients with an identified CD? Can you describe the model used? Case management refers to planning, coordinating, managing and reviewing the care of an individual patient. This may involve, assigning each person a 'case manager' who is responsible for assessing patients' needs; developing a care plan, arranging suitable care; monitoring the quality of care; and maintaining contact with the patient and their family.

Chronic disease prevention programmes
Does the health service have any chronic disease prevention initiatives in place? Can you describe the initiatives that are in place?

Onsite Pharmacist
Is there an onsite pharmacist?

Access to Section 100
Does the health service have access to Section 100 arrangements for the supply of pharmaceutical goods?

Home medicines review process
Is there a process in place for conducting Home Medication Reviews and claiming the available Medicare rebate?

Monitoring adherence
Is there a process for monitoring adherence? Describe

Computerised record system
Is there a computerised Patient Information and Recall System (PIRS) in use?

Automated pathology
Is there an automated system for receiving pathology results?

Routine population data
Is there a formalised mechanism for providing regular population health data to the community and health service staff?

Recall system
Is there a client recall system in place that supports the delivery of or 'recalls' individuals to receive scheduled services?

Chronic disease register
Is there a register of all clients with chronic disease?

Hospital Liaison
Record if the health service employs a hospital liaison officer.

Care planning includes hospital staff
Record if hospital staff are included in the development of Team Care Arrangements [EPC 723 or equivalent].

Communication, Accessibility and Consistency of Hospital Based Services.
The following questions seek to build consensus among focus group participants, by considering the usual process and barriers to care and ease of communication between primary care staff and hospital staff when arranging [or attempting to arrange] admission, referral, assessment and management by specialists within hospitals, and that occurs following a patients' discharge from hospital.

Admission:
Describe the ease of communicating with and accessibility of hospital services when attempting to arrange the admission of a patient to hospital for assessment or management?