Partnership approach to Indigenous primary health care and diabetes: a case study from regional New South Wales

Type 2 diabetes is a major problem in Indigenous Australians, who have a higher self-reported prevalence (11%) than the general population (3%).1 The self-reported prevalence is probably a considerable underestimate, as the AusDiab study found a national prevalence of 7.4% with glucose tolerance testing, but had inadequate numbers to estimate the prevalence among Indigenous Australians.2 Onset occurs at an earlier age, and results in greater morbidity and mortality from the complications of diabetes.1 Despite the fact that complications are avoidable or manageable with appropriate community-based primary health care,3 diabetes was implicated in 18% of all deaths of Indigenous people in 1999–2001.1 Guidelines identify an annual cycle of care recommended for managing diabetes,4 but in rural areas, the lack of specialised diabetes clinics, shortages of health workforce, large distances and poor transport infrastructure make these difficult to follow for any population group. Many Indigenous people do not access health care until an acute event when it is difficult to reverse the complications of diabetes,5 leading to a situation where a population group with extreme need has very poor access to appropriate care. In the Northern Rivers of New South Wales (NSW), Indigenous people form 3.2% of the population.5 The Dharah Gibinj Aboriginal Medical Service (AMS) in Casino provides care for approximately 4000 members of the Bundjalung Nation or ‘Goorie’ community. Goorie is the term that Aboriginal people of the Bundjalung Nation use for themselves, and Dharah Gibinj means rubbing or massaging. The AMS also provides outreach clinics at several smaller, more isolated communities. Prior to 2004, management of diabetes in the area serviced by Dharah Gibinj was uncoordinated and sporadic. In 2003 the local diabetes service, consisting of a diabetes educator and dietitian, saw 15 clients with no opportunities for other health professionals to participate in assessment and care. No data exist on attendance rates at medical practices; however, anecdotal evidence indicates similar low attendance rates and fragmented care. In 2004 the Primary Health Care Network (PHCN) was funded by NSW Health. The PHCN team conducted an extensive consultation with elders, local communities and health professionals, identifying gaps in health care delivery (Table 1). It was evident that a new approach was needed. Best practice in diabetes management suggests that an integrated and coordinated approach is the most effective way to provide services to Indigenous communities.5 A multidisciplinary Goorie Diabetes Complication and Assessment Clinic (DCAC) has been established to provide comprehensive outreach services in four isolated rural Aboriginal communities around Casino. Venues vary from a well-equipped medical centre to an old school building two-hours drive from the base hospital. The Goorie DCAC team brings health professionals from the AMS, the North Coast Area Health Service (NCAHS) and private specialists into each of the four communities on a monthly rotating basis. It focuses on primary and secondary care and interventions to prevent further complications related to undiagnosed or poorly managed diabetes. The DCAC team includes a specialist physician, GP, ophthalmologist, Aboriginal health education officers, Aboriginal health workers, diabetes educator, dietitian, podiatrist, laboratory scientist and a renal nurse. Clients are referred to the DCAC by their GP. Clinic staff use a holistic approach with assessment of a range of risk factors and health issues, includingcul tural and environmental factors, affecting the individual's health. In conjunction with the referring GP, a single-visit clinic provides the annual cycle of diabetes care for all diabetic clients, ensuring multidisciplinary input. It maximises convenience for clients by providing screening and evidence-based management for diabetes and its complications while removing the need for multiple visits to a variety of care providers. The flow of patients through the clinic is shown in Figure 1. Flow of clients through the Goorie Diabetes Complication and Assessment Clinic (DCAC). BMI, body mass index. One of the strengths of the DCAC is the collaboration with NCAHS Pathology, which provides point-of-care pathology testing. This flexible approach enables accurate, timely and appropriate client test results to be available in the clinic. Each client has a point-of-care pathology report issued, which includes lipid profile, HbA1c, microalbuminuria, and albumin : creatinine ratio, which they take with them as they see each provider. Combined with the clinical assessment, this gives valuable information for management and immediate feedback to the client. Analysers, centrifuge and venepucture equipment are transported to the community with calibration prior to each clinic. Further testing is subsequently undertaken at the main laboratory, with confirmation of the point-of-care results. At the completion of each clinic, team case conferences are held to develop management plans. Clients' assessments are discussed and where needed, further referrals and follow up are organised, ensuring that evidence-based clinical pathways are followed. Reports are sent to the clients' GPs and other relevant clinicians, together with reports of any additional laboratory test results. Care coordination is initiated for individuals with a high risk of developing complications, including support for basic requirements, such as food, medications and transportation to other specialist services. The Aboriginal health professionals from each community are crucial to the clinic's success. They encourage community members to attend and provide a culturally safe environment by welcoming clients and making them comfortable. They also inform other team members about relevant environmental and community issues. A number of changes have been made to the running of the clinic in response to their knowledge of local issues. Aboriginal health professionals also receive regular formal and informal education on diabetes and vascular health, and have been trained to assist in the laboratory, administer eye drops, take anthropometric measurements, calculate body mass index, and test visual acuity using a Snellen chart. They have an increasingly important role in providing clinical support. The clinic welcomes all Aboriginal community members, providing screening for diabetes, as well as management of diabetes and its complications. Some whole-family groups attend the clinics, and a small number of elders without diabetes consistently attend for screening, acting as leaders and role models for their communities. The clinic provides lunch, which proves to be a good social exchange between staff and the communities. The Bundjalung Nation are a proud and unique people who did not want generic health-promotion materials developed for other Indigenous groups, but preferred materials targeting Goories specifically. These were developed in association with the elders, Aboriginal health professionals and Bundjalung artists, and are used in the clinic and provided to clients. Pathology data indicate that from January 2004 to November 2005, 167 people had attended the clinic at least once and had an HbA1c test conducted. Of them, 77 were known diabetics attending for assessment and management, and 90 were people attending for screening. Among the known diabetics, 21 (27%) had an HbA1c result ≤7.0%, and disturbingly 27 (35%) had an HbA1c >9.0% on their first visit, reflecting previous poor management and control of diabetes. Fifty-two of the diabetics have returned for at least one subsequent visit. This represents a massive increase in access compared with the situation prior to establishment of the DCAC, in which care was either non-existent or completely fragmented. In 2003, only 15 people attended the AMS diabetes service, which consisted of a diabetes educator and dietitian only. Other developments from the program include the AMS joining ‘Quality Assurance for AMS’, a national quality assurance program for pathology services. Dharah Gibinj is also one of the few AMS to become a Diabetes Australia, National Diabetes Service Scheme provider, enabling easier access for the clients to purchase diabetes equipment supplies such as blood glucose strips and needles. There is growing evidence that a structured approach to caring for Indigenous Australian's with chronic conditions such as diabetes can significantly improve quality of life, clinical outcomes and cost to the community both emotionally and financially.6 The DCAC team responds to local needs, working within local structures and supporting the Indigenous community by delivering culturally safe, accessible and effective strategies for improving health care for diabetics and those at risk. The team facilitates continuity of care by working across community services and between the acute, community and general practice settings, and by identifying gaps in service delivery to ensure best practice management. The project combines primary and secondary care wherever possible, to identify and treat complications related to undiagnosed or poorly managed diabetes in the community setting. The success of our program has largely resulted from establishing close ties between the Aboriginal communities and the DCAC team, through both formal structures and informal relationships. Being based within a community-controlled health service has provided a formal mechanism for ensuring community input and developing the program in a culturally acceptable way. This has allowed us to respond to both individual and community issues and tailor our approach accordingly. The next phase involves establishing systems for monitoring outcomes and working with the community and other service providers, to identify further ways to improve the clinic and support the clients to make the required lifestyle changes. A research project addressing adherence to medication regimes has recently commenced. While considerable work has been carried out on developing suitable models for providing chronic disease management in remote communities,7–9 there is little published on how to meet the challenges in regional communities. Our model might be applicable in both regional and metropolitan Aboriginal communities. To our knowledge, the Goorie DCAC is the first of its kind in Australia. We hope that others interested in addressing the problems of chronic diseases in Aboriginal communities might be able to learn from our experiences. Other members of the Goorie DCAC team include: Dr Malcolm Tester, Graeme Walker, Marlene Binge, Christine Williams, Helen McGregor, Tim Torrens, Maryann Young, Evelyn Robinson, Ron Knight, Cheryl Ducat, Marion Close, Angus Binge, Sandra Reid, Isabel Jefferies, Jo Stewart, Gloria Torrens, Warren Williams and Karen Kennedy. We wish to thank the managers from the health services, Lisa Beasley, John Tranter, Vicki Rose and Rosemary Laurie for their ongoing support and commitment to the clinic; and the members of the project working party, Kerry Wilcox, Chris Murphy, Jacqui Beaumont and Jacki Frogley for their guidance and support. Most importantly, we wish to thank the elders from the communities: Uncle Eric Walker, Pastor Francis Bundock, Aunty Grace Cowan, Aunty Phyllis Torrens, Aunty Josie Walker, Uncle Robert Caldwell, Uncle Bruce Walker, Uncle Ken Randall, Uncle Charles Moran, Aunty Jenny Murray, Aunty Mavis Murray and Aunty Rita Torrens for their support for the clinic, for the guidance they have provided in its development and implementation, and for their permission to publish this article. Jo Cooper 30%, Stephen Moore 10%, Lyndall Palmer 10%, Judy Reinhardt 10%, Mick Roberts 10%, Anthony Solomon 10%, Megan Passey 20%.