Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012
Tier 3—Effective/appropriate/efficient—3.05 Chronic disease management
Why is it important?:Chronic diseases such as circulatory disease, diabetes, renal disease, chronic respiratory disease, cancers and chronic mental health conditions are the major causes of morbidity and mortality among Aboriginal and Torres Strait Islander peoples. Better management of these conditions is a key factor in meeting the target of closing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation. Chronic disease is estimated to be responsible for 70% of the health gap (Vos et al. 2007). Effective management of chronic disease can delay the progression of disease, improve quality of life, increase life expectancy, and decrease the need for high cost interventions. Good quality care for people with chronic disease generally involves multiple health care providers across multiple settings and the engagement of the client and their families in self-management of the condition (NHPAC 2006). Typically, the primary health care provider plays a central role in chronic disease management through systematic or opportunistic screening to identify patients with asymptomatic disease, development of a management plan with the patient and their family, regular assessment of the extent to which the chronic illness is well controlled, regular checks to identify early signs of complications, and referral to specialist care where this is warranted. Chronic disease management requires early access to specialist care where necessary, with primary care providers continuing to play a key role in the management of the disease. To play an effective role in chronic disease management, primary health care services need to take an organised approach reflecting evidence-based guidelines (Wagner et al. 1996; Bodenheimer et al. 2002). The Medicare Benefits Schedule includes GP management plans and team care arrangements to support a structured approach to management of patients with chronic or terminal conditions.
Findings:Medicare claims data show that there has been an increase in the number of GP management plans and team care arrangements claimed by Indigenous Australians between 2009–10 and 2010–11. Over this period GP management claims increased from 23,927 to 32,717 and team care arrangements from 18,680 to 26,525. Rates were nearly twice as high for these services for Indigenous Australians compared with non-Indigenous Australians. There has also been a corresponding increase in allied health care services claimed through Medicare by Indigenous Australians with dental up from 77,343 to 122,822 and other allied health from 25,961 to 35,731. Indigenous Australians also had a higher rate of nurse/Aboriginal Health Worker consultations claimed than non-Indigenous Australians (522 per 1,000 compared with 257 per 1,000).
Information on the management of chronic conditions by Aboriginal and Torres Strait Islander primary health care services is available through OATSIH Services Reporting (OSR) and the Healthy for Life collections. Through OSR data for 2010–11, it was estimated that approximately 63% of services employed a doctor and 85% provided management of chronic illness. Services also report on whether they have systems in place which assist with clinic operational practices, particularly for the provision of services to people with chronic disease. In 2010–11, 70% of services reported keeping track of clients needing follow-up, 74% maintained health registers (e.g., chronic disease register), 75% used clinical practice guidelines, and 72% used patient information and recall systems (PIRS) that automatically provide reminders for follow-up and health checks. Between 2001–02 and 2010–11 there has been a significant increase in the proportion of services maintaining health registers, using PIRS systems and utilising clinical practice guidelines.
A range of quality improvement approaches are being implemented across general practice and Aboriginal and Torres Strait Islander primary health care services in Australia, including the Australian Primary Care Collaboratives, the Audit and Best Practice for Chronic Disease (ABCD) program (now under the auspice of One21seventy CQI cycle) and the Healthy for Life program. By 2009, 62 health centres were participating in the ABCD program. Earlier research under the ABCD program demonstrated that the proportion of Indigenous Australians with Type 2 diabetes receiving six-monthly HbA1c tests could be increased from 41% to 72% in remote locations (Bailie et al. 2007).
The Healthy for Life program supports quality improvement processes in 100 services through 59 sites across Australia. In 2010 around 13,264 regular clients of these services had Type 2 diabetes. In the six months to June 2010, around 52% had an HbA1c test performed and 62% had their blood pressure assessed. For the services that reported the results of these tests, 68% had HbA1c levels that were higher than the recommended level for people with diabetes (i.e., less than or equal to 7%), and 56% had elevated blood pressure. For Indigenous Australians with coronary heart disease who are regular clients, 69% had their blood pressure assessed in the last six months. For the services that reported the results of these tests, 38% of people with coronary heart disease had elevated blood pressure.Top of Page
Implications:The provision of organised chronic disease management in Aboriginal and Torres Strait Islander primary health care services has resulted in improvements in various health outcomes (Hoy et al. 1999; Hoy et al. 2000; Rowley et al. 2000; McDermott et al. 2003; Bailie et al. 2007). However, there are significant challenges in sustaining improvements in the management of chronic illnesses (Urbis Pty Ltd 2009). Strategies recommended to address these challenges include systematic support to buffer the effects of local factors, transparent work-practice systems backed by written disease management guidelines and manuals, delineated roles for practices for all practitioner types, appropriate staffing and training policies, and raising awareness in communities through education and health promotion with strong local participation (Bailie et al. 2004).
Australian governments are supporting various initiatives to improve chronic disease management including through the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. The Practice Incentives Program—Indigenous Health Incentive includes payments to GPs for registering with the program, for registration of Indigenous patients with chronic disease and providing best practice management of chronic disease. Early findings from Medicare data reported here show an increase in the number of GP Management Plans and Team Care Arrangements claimed through Medicare since the introduction of the program. In November 2009, the MBS was amended to allow practice nurses and Aboriginal Health Workers to provide additional follow-up care after an Aboriginal and Torres Strait Islander Health Assessment, with an increase from five to 10 MBS-rebated items per year per person. In 2010–11, 13,413 Indigenous-specific follow up services were provided by Aboriginal health workers and practice nurses, representing an increase of 10,246 services from 2009–10.
The Medical Specialist Outreach Assistance Program—Indigenous Chronic Disease is currently in its third year and has committed $54 million over four years for the operation and funding of multidisciplinary teams comprising specialists, GPs and allied health professionals. Its aim is to improve the management of complex and chronic health conditions in rural and remote Indigenous communities.
The Quality Assurance for Aboriginal and Torres Strait Islander Medical Services program aims to provide culturally appropriate and clinically effective diabetes management through the use of ‘point of care’ pathology tests. Other initiatives addressing chronic disease include the support of the Australian Primary Care Collaboratives and the Healthy for Life program. GP Super Clinics will also provide multi-disciplinary, integrated team-based approaches to deliver better prevention and treatment of chronic disease.
Other local arrangements also exist, for example the Care Connect Pilot in Qld provides early intervention services to reduce the burden of renal and other chronic disease experienced by Aboriginal and Torres Strait Islander peoples. This program also provides a care coordination service that assists people to access appropriate services and monitors the progress of patients to help them navigate the health system.Top of Page
Figure 155—Number of selected MBS services claimed, Indigenous Australians, 2009–10 and 2010–11
Source: Medicare Financing & Analysis Branch, Department of Health and AgeingTop of page
Figure 156—Age-standardised rate of selected MBS services claimed, by Indigenous status, 2009–10 and 2010–11
Source: Medicare Financing & Analysis Branch, Department of Health and AgeingTop of page
Figure 157—Proportion of Indigenous regular clients of Healthy for Life Services receiving recommended care, 1 January to 30 June 2010
Source: AIHW analysis of Healthy for Life data collectionTop of page
Figure 158—Proportion of Indigenous Australians with Type 2 diabetes receiving recommended care, 12 remote primary care services, the NT, 2003–04 to 2005–06
Source: (Bailie et al. 2007)Top of Page