Journal article

Addressing profound disadvantages to improve Indigenous health and reduce hospitalisation

A Collaborative Community Program in Remote Northern Territory
Journal
Remote health Primary health care Indigenous health Katherine
Description

Abstract:
Aboriginal people in rural and remote areas of the Northern Territory of Australia have suffered longstanding issues of homelessness and profound health and social inequities. The town and region of Katherine are particularly impacted by such inequities and have the highest rates of homelessness in Australia, composed almost entirely of Aboriginal people who represent 51% of the total population of 24,000 people. The region is serviced by a 60-bed hospital, and a small cohort of frequent attenders (FAs) represent 11% of the Emergency Department (ED) case load. The vast majority of FAs are Aboriginal and have very high burdens of social inequity and homelessness. FAs are a challenge to efficient and effective use of resources for most hospitals around the world, and investment in programs to address underlying social and chronic health issues contributing to frequent attendance have been demonstrated to be effective. Methods: These are the interim findings of a prospective cohort study using five sources of linked health and related data to evaluate a community-based case management pilot in a culturally competent framework to support frequent attenders to the Katherine Hospital ED. FAs were defined as people with six or more presentations in 12 preceding months.
The intervention composed of a community-based case management program with a multi-agency service delivery addressing underlying vulnerabilities contributing to ED presentations. Results: Among this predominantly Aboriginal cohort (91%), there were high rates of homelessness (64%), food insecurity (60%) and alcohol misuse (64%), limited access to transport, and complex comorbidities (average of 2.8 chronic conditions per client).

Objectives: 
To explore how to improve health service utilisations for Aboriginal people in the Katherine region. It is hypothesised that the true effects of WSP will be more evident in future analyses, as the protective factors of the program slowly mitigate years of exposure to environmental, social, psychological, and medical risks. 

Importance of study:
This study, which enrolled Indigenous people living in remote locations, is consistent with previous urban-based research demonstrating high rates of comorbidities in FAs [20]. The consequences of homelessness and overcrowded housing that is so prevalent in Indigenous communities across Australia, particularly in tropical environments, exacerbate the severity of illness and need for hospital care. For example, a key driver of RHD is overcrowded housing and associated high streptococcal carriage and untreated infections; rates of RHD in this study were much higher than baseline rates within the NT, even though prevalence in the remote NT is amongst the highest in the world, suggesting overcrowded housing since childhood for WSP participants. Of serious concern is the fact that the majority of Indigenous people on dialysis in this study were homeless. In most regions of Australia, it is assumed that people on dialysis have ready access to food and transport, and that they live in a clean and safe home

Study type: 
The study design was a prospective cohort comparing pre- and post-intervention outcomes in the same individual, accounting for differences in time enrolled in the program, and presenting an interim analysis conducted 10 months into a planned 24-month follow-up period. The design was reviewed by clinicians and cultural representatives from KH, Menzies School of Health Research, WWHS, KCA, and other non-government organisations in Katherine.

Results: 
The challenges facing Aboriginal people in the Katherine region and other towns and communities in the remote tropical north of Australia are extreme. The WSP is a grass roots community-driven attempt to address the social determinant needs of a highly vulnerable demographic in the region. We found a significant reduction in ED presentations and increase in engagement with primary health care following the intervention, which represents more efficient and sustainable engagement with the health system. This intervention has demonstrated that EDs are ideally situated to go beyond band-aid solutions and address the deep social roots driving the bigger picture, implementing the right care, in the right place, at the right time, one very vulnerable person at a time.

Conclusion:
The challenges facing Aboriginal people in the Katherine region and other towns and communities in the remote tropical north of Australia are extreme. The WSP is a grass roots community-driven attempt to address the social determinant needs of a highly vulnerable demographic in the region. We found a significant reduction in ED presentations and increase in engagement with primary health care following the intervention, which represents more efficient and sustainable engagement with the health system. This intervention has demonstrated that EDs are ideally situated to go beyond band-aid solutions and address the deep social roots driving the bigger picture, implementing the right care, in the right place, at the right time, one very vulnerable person at a time.

Key Findings:

  • The extreme health disparities suffered by Indigenous people testify the failures of ‘western health care’, and this is deeply evident in Katherine. 
  • The WSP has demonstrated promising interim results, including more effective utilisation of health services, secondary to the implementation of a culturally designed collaborative case management model of optimising services and supporting medical and social vulnerabilities in this population. 
  • The results of this study demonstrate an increase in ambulance utilization after program commencement. The patterns of utilization demonstrated an increase in ambulance use by those with a higher burden of comorbidity who presented less frequently, and a decrease in those with low levels of comorbidity who had alcohol use disorder and who presented more frequently.
Publication Details
DOI:

10.3390/ijerph16224306

Publication Year:
2019