How to Address Inequity for Indigenous Patients in the Australian Health System: Samuel’s Story

Xiang-Yu Hou; Yashni Kander; Roxanne Bainbridge

How to Address Inequity for Indigenous Patients in the Australian Health System: Samuel’s Story

by Xiang-Yu Hou^1*, Yashni Kander², Roxanne Bainbridge¹

¹Poche Centre for Indigenous Health, The University of Queensland, Brisbane, Australia.

²Aboriginal and Torres Strait Islander/Multicultural Health, Patient Flow Services, The Royal Brisbane and Women’s Hospital, Brisbane, Australia.

*Corresponding author: Xiang-Yu Hou, Poche Centre for Indigenous Health, The University of Queensland, Brisbane, Australia.

Received Date: 05 February, 2024

Accepted Date: 12 February, 2024

Published Date: 14 February, 2024

Citation: Hou X-Y, Kander Y, Bainbridge R (2024) How to Address Inequity for Indigenous Patients in the Australian Health System: Samuel’s Story. Rep GlobHealth Res 7: 187. https://doi.org/10.29011/2690-9480.100187.

Abstract

Objective: The objective of this study is to critically analyse the health system reasons behind a success story of an Indigenous patient from a rural area in Queensland Australia receiving timely high-quality acute surgical care in a large urban hospital, including his transitions from primary to tertiary care.

Method: We used a patient journey mapping approach to document, analyse, and reflect an Indigenous patient’s experience of receiving a surgical care for an eye injury, and the potential reasons behind the success focusing on the health system.

Results: Improvements in the quality of care were demonstrated by the patient’s positive personal admissions. His stated experience of hospital care shifted from “For us Indigenous people, we don’t really like going to hospitals because we feel frightened” to “‘Every time I have a hospital appointment I can’t wait to come’. The patient’s improved quality of care was attributed to 1) the holistic and integrated care experienced from the Primary Health Care staff, Indigenous Liaison Officers, the eye clinic team and the nurse navigator at the hospital; 2) having a rapport and trust relationship via yarning with the patient; 3) high level of satisfaction with the nurse navigator as a care coordinator, communicator, and advocator.

Conclusion: A health system with staff who are culturally and clinically competent and provide the whole-person care for Indigenous patients could be vital in achieving the goal of Close the Gap.

Keywords: Health System; Health Services; Health Equity; Indigenous patients; Aboriginal and Torres Strait Islanders; Australia.

Introduction

Background

The Australia government is among the leading countries in the world that is determined to close the health gap between Aboriginal and Torres Strait Islander (here after respected referred to as Indigenous) people and non-Indigenous people. One of the strategies is to improve the access to appropriate, highquality, and timely health care throughout life. For example, access to hospital procedures (proportion of hospitalisations for Indigenous Australians where a procedure was recorded), has been significantly improved the last decade [1]. Explicit Indigenous Australian health policy aims to improve access to appropriate, high-quality, and timely health care throughout the lifecourse. However, many challenges and barriers remain in the Australian health system for Indigenous patients, which affect their access and experiences of healthcare. One of them is the care transition.

The complexity of the Australian health system make care transitions a challenging feature for many health service users, especially for those who hold different value systems and beliefs to that of Western models of care, have complex care needs, and/ or are in rural and remote locations. For instance, some of these challenges, that could be associated with the quality of care transition, can be observed in 1) the increase of Discharge Against Medical Advice [2] (DAMA, the rate at which Indigenous hospital patients leave hospital without completing treatment) over the last decade; [1] and 2) survival outcomes such as adjusted long term mortality and median number of potential life years lost were higher for Indigenous than non‐Indigenous patients after intensive care in hospital [3, 4].

System fragmentation and the documented evidence of care transitions of many patients test the adequacy and flexibility of health systems to provide access, and effective, efficient, and appropriate care. Strategically, integrated care has remedial value to system fragmentation [5, 6]. It requires care coordination which “is the deliberate organisation of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services” [7], and coordination across organisations and sectors in the health system that improves patient experiences, health outcomes and system efficiencies [8]. Theoretical support for care integration is abundant but practical methods of design and implementation to achieve improved patient experiences, health outcomes, and system efficiencies are limited [8]. There are, however, pockets of promising practices that demonstrate that improvement is possible.

In writing this paper, we proffer a case example of care coordination and nurse navigators that profoundly changed the transitional care experiences of an Indigenous surgical patient from a rural location to a major urban hospital. The paper aims to provide empirical evidence and insights into the value of an existing transitional care navigation model in the Australian health system, and to provide some clear recommendations to reorient the health system to improve quality of care and health equity for Indigenous Australians.

Methods

To explore this health system performance issue, we took a patient journey mapping approach to critically analyse the surgical pathway experienced by a rural-dwelling Indigenous patient who received timely and quality surgical care in a tertiary hospital in Brisbane, Queensland, Australia.

In June to November 2020, the Royal Brisbane and Women’s Hospital has implemented an initiative, called Health and Wellness Check, a culturally appropriate preoperative telephone health and wellness check that will improve surgical attendance rates and their experiences for Indigenous elective surgery patients [9]. A key element of this initiative is a nurse navigator [10]. This article is to present a success story about an Indigenous patient Sam and a nurse navigator Yashni.

Result

Samuel is a Lama Lama and Gugu Yimithirr man and Palm Island resident, a devout Christian who attends church every Sunday. He accidentally had a pocketknife lodged in his right eye when he was kindly helping a friend to cut some zip ties loose from a valve on the motor [2].

He went to emergency surgery at Townsville Hospital, Queensland, Australia, and his eye was stitched up. Then he was advised to be flown down to the Royal Brisbane and Women’s Hospital (RBWH) to undergo further surgery. The next day Samuel boarded the plane to Brisbane with his father Lawrence.

Upon arriving at the RBWH, Samuel was admitted and taken immediately for more surgery [2].

Coming out of his second surgery, Samuel was placed in the Ophthalmology ward. That was during COVID-19 time. “Yashni [Nurse Navigator] organised for my dad to get a special pass that allowed him to visit me, … I was feeling really alone, so to have my dad be able to just sit there and yarn to me eased my mind and my pain. ... Yashni is a legend.” [11], said Samuel.

When being asked about his eye care journey, Samuel said the following: [11].

“I have never received care like they provided me at the RBWH. … Whether it’s a different nurse who is taking over, they’re just caring for me, constantly checking up on me. … I honestly felt really cared for and loved, and felt like I was an actual person, and not just a patient.”

“If I wanted extra blankets, because I wasn’t used to the cold, and it was winter, they would give me extra blankets and pillows.”

“Caleb [Indigenous Hospital Liaison Officer] took me to the shops and back, that stuff is unheard of in other hospitals …. Being away from your community and your comfort zone, and to get that type of help, it was such a blessing”.

“For us Indigenous people, we don’t really like going to hospitals because we feel frightened, and don’t like getting rejected. The care I received at RBWH was beyond anything I thought hospitals do. … it has honestly won my heart over.”

So, now ‘Every time I have a hospital appointment I can’t wait to come’.

There is no doubt that the health and wellness support Samuel received from Indigenous Hospital Liaison Officers Caleb and the Nurse Navigator Yashni, plays vital role in his willingness to attend hospital to receive continuous care, which consequently facilitates his recovery from his eye injury and surgeries.

Now you see the story from a patient’s personal experience. Next, we share the activities behind the scenes and insights from this patient’s journey.

Logistics Support

For one patient, in addition to many phone calls, there were more than 20 emails - some emails a few pages long - for timely communication including after business hours about bookings, cancelling, and re-booking of clinic appointments, flights, ground transport, and hotel accommodation between Yashni and Indigenous Liaison Officers (ILOs) and Travel Office in Townsville, and clinicians in the department of Ophthalmology at RBWH. Yashni also reminds the department clinicians that Samuel “gets nervous to ask questions.”

Additionally, Yashni encouraged Samuel to take up COVID 19 vaccinations and supports him to deal with requests from Centre Link. Here is an example of Yashni’s email “Centrelink advised that he has been asked to look for work and has been offered garden maintenance e.g., mowing on Palm Island. Can you please help him to access the Specialist Medical Certificate document and ensure he brings this to Brisbane in 2 weeks? The Ophthalmologist will complete this for him as this will be too risky for him given that he requires more surgery to his eye.”

There is a pattern in Samuel’s journey. Yashni communicates with the clinic to book the hospital appointment, informs the Townsville team to book the suggested flights and accommodation for Samuel and his father. If there is any event that stopped the patient from attending the appointment (Fail to Attend), Yashni repeats the process by communicating with Ophthalmology Outpatients making another appointment, another email to suggest flights and accommodation. When Samuel finally attends the clinic, Yashni accompanies him when she is available, to make sure that he is not too scared to ask questions and to tell the clinicians if he is in pain, or tell them that he needs lunch etc.

Clinical Support

In addition to the logistic support, the clinical support by Yashni’s team has also been vital. For example, in Yashni’s email dated 12/1/2021, she had to explain to the Townville ILOs that “Samuel is to continue to use his eyedrops, dab the eye gently. The oil will stay in likely for 3-6 months as the risk is high for detachment and bleeding.” On 8/11/2021, “He has been advised to lay down on right side when sleeping. Provided a new script for 2 eyedrops to continue 3 time per day, AM and PM. … Samuel reports constipation and forgetting things since the surgery. I have asked him to discuss with his GP.”

Here is another example of support in clinical care. After the surgery, Samuel stayed in the hotel across the road from RBWH. When Yashni saw him at the clinic, he was crouching over and covering his head with his hands.

Yashni looked at him and asked: “what’s wrong?”

“I am in so much pain. I am struggling.”

“Did you tell anyone?”

“No.”

“How long have you been in that pain?”

“A few days.”

“Why didn’t you come cross to the hospital?”

“Because I did not think I was allowed to.”

Quickly, Samuel received his pain relief and felt much better; and was told that if he has any emergency issue, come to the emergency department straightaway.

During the journey of his eye care, Samuel grows in confidence, understands more about the hospital system and that he is part of the system. He knows everyone is action orientated to support him.

Because of Samuel’s need for ongoing medical treatment and plans to have a lens inserted into his eye to improve his vision, Samuel will continue coming to the RBWH for another year or two to receive care.

There are many cases like Samuel since the establishment of the team Nurse Navigators for Indigenous Patients in 2021. Their service includes a culturally appropriate pre-surgery screening to all Indigenous patients at risk of patient-initiated cancellations. Their results of the six-month implementation phase demonstrated a 33.3% decrease in failing to attend (FTA) and an 82.4% decrease in patients calling to cancel surgery within 24 hours of surgery [12].

Professional and Personal Reflection

There are three key reasons for Samuel’s experience of timely, appropriate high quality transitional care.

The support from the Primary Health Care staff, ILOs, the eye clinic team, and the nurse navigator is instrumental for this successful case. The whole-person support covers the patient’s travel, hotel booking, appointments booking, checking in with him, and connecting with him.
Having a rapport and trust relationship via yarning with patients, finding out what their concerns and needs are, and frequently checking if they do understand what is going on.
A nurse navigator as a coordinator, communicator, and advocator: When a nurse navigator accompanies the patient, it makes a big difference how responsive clinicians are, simply because they can better understand the patient’s situation.

Based on Samuel’s case example, reorienting the health system to be more patient-focussed requires four main considerations; all of which align with current health policy and require a move to well-coordinated integrated care and working with people as partners in the own health. These strategies are:

Improve the quality of clinical interactions including the care transitions. Our health system needs to allow and encourage clinicians to provide extra time to accommodate patients with extra needs, such as Indigenous patients, multicultural patients, and patients with disabilities. This advice has been repeatedly recommended in published research [13].
Clinicians need to be trained in cultural awareness. This recommendation is also supported by research evidence [5]. Further, the lessons learnt from the courses need to be applied in daily practice, such as spending some extra time talking to the patients, checking what the patient’s understanding is and what their concerns are, and supporting them in culturally safe ways.
Employ more clinically and culturally competent nurse navigators across the health system.
Increase the Indigenous workforce to support Indigenous patients. It is a common sense to increase the Indigenous workforce who can provide the social and emotional support to Indigenous patients [14].

Samuel’s wish to share his story is to “encourage people to access health services and hospitals and seek health care when they need to” [11]. Similarly, our wish to share this personal reflection and analysis is to encourage leaders, managers, and clinicians in the health systems in Australia and other countries to take timely actions to address the inequity of access and use of healthcare by Indigenous people.

Conclusion

This case study demonstrates that a tertiary hospital with staff who are culturally and clinically competent and can provide the whole-of-person care for Indigenous patients, including the transitional care between primary and tertiary healthcare, could be vital in achieving the goal of Close the Gap.