New Chronic Care service for St Vincent's First Nations patients

28 Oct 2022

St Vincent’s has recently commenced a new service, aimed at reducing the rate of non-planned readmissions for Aboriginal and/or Torres Strait Islander patients. Following an analysis of the disproportionately high readmission rate, common themes were revealed around factors leading to unplanned readmissions. The new service aims to address these factors with tailored care and coordination, empowering patients’ to better manage their chronic or complex health conditions in the community, keeping them healthy and out of hospital.

The St Vincent’s Aboriginal and/or Torres Strait Islander Chronic Care Coordination Service is the only NSW hospital-based Chronic Care role targeted towards Aboriginal and/or Torres Strait Islander peoples. One of the key objectives of this service is to facilitate comprehensive, personalised and culturally appropriate discharge planning for our Aboriginal and/or Torres Strait Islander in-patients living with chronic disease, and ensuring they have ongoing support once they leave the hospital.

Aboriginal Chronic Care Coordinator, Damien Davis Frank leads the service working closely with the Aboriginal Health team. In this role Damien supports Aboriginal and/or Torres Strait Islander patients living with chronic health issues including cardiac disease, cancer, renal disease, diabetes and lung disease. Additionally, he works alongside patients with other complex conditions affecting their health including mental ill health, substance use and homelessness.

“Mainly I’m dealing with admitted patients but I also see patients in Emergency, especially if they have chronic illness and they’re going to be discharged. If someone is recognised as being a frequent presenter which could be the result of complex health issues, then we need to explore that as well”.

And by making clinicians and treating teams aware of some of the factors they might not have been considered in their initial assessments, Damien can ensure that every service that needs to be involved in the patients’ care is actively included.

“As an advocacy role, I can think about the best interests for the individual without being influenced by external hospital pressures. The role also allows space to help educate colleagues about factors affecting Aboriginal and Torres Strait Islander patients' health and wellbeing, such as intergenerational trauma and institutionalised racism to help provide culturally safe and tailored care. Also taking in to consideration more strategic factors, such as patient flow, and being there to support and partner with that person to better understand their health goals so we can and push for the best health outcome”.

Damien ensures that patients know their medical team and what they are seeing them for, when and where their community appointments are, and that they can access bulking billing for GP appointments and scripts.

“It’s about ensuring that the discharge plan is tailored to them, that patients are properly connected back into community, and that the patient is confident with their health plan and goals.”

In addition, Damien provides specific health coaching and education, ensures patients are able to look after themselves when they leave the hospital, or that they have a carer at home, and finds robust supports for those who don’t.

While this new service commenced just a few months ago, already it’s proving to be invaluable.

“One of the patients I’ve been working with has had over 90 presentations to Emergency over the past year from August 2021-August 2022. I started care coordinating with him in mid-august and in the 6 weeks since we’ve started working together, his presentations to Emergency had halved”.

For more information about the Aboriginal and/or Torres Strait Islander Chronic Care Service, please click here.

Damien

Damien Davis Frank