Sammi: Good afternoon everybody and welcome to this afternoon’s cardiac rehabilitation for Aboriginal and Torres Strait Islander People webinar. My name is Samantha and I will be your host this afternoon. Before we jump in I am actually going to hand over to one presenters, Joe Bryant who is a man local to the Gumbaynggir Nation on the mid-north coast to take us through our Acknowledgement of Country that is up there.
Joe: Good evening everyone. My Name is Joe Bryant from the Gumbaynggir Country on the mid-north coast. I am the Gumbaynggir mayor and I would like to do an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work. We pay our respects to Elders past, present and emerging, and any Aboriginal people who are joining in for the webinar.
Sammi: So in saying that, I would now like to introduce our presenters for this afternoon. So, we are joined by Cate Ferry. Cate is a healthcare professional with qualifications in nursing and public health. She has extensive experience in the healthcare environment, not just in clinical practice but in projects management. Cate has worked at the National Heart Foundation of Australia New South Wales as the Manager for Clinical Programs since 2008. In this role, she collaborates with a range of stakeholders including clinicians, healthcare services, researchers and cardiac consumer and advocates people at risk and with cardiovascular disease to receive appropriate, evidence-based care that spans pre-hospital, hospital and includes ongoing secondary prevention.
We are also joined by Joe Bryant. Joe is a project officer for the Lighthouse Hospital project and a physiotherapist, and as he mentioned he is also a man from the Gumbaynggir Nation on the mid-north coast.
We are joined by Raj as well. So Raj is a clinical cardiologist at RPA and consulting Cardiovascular MR at RPAH and Children’s Hospital Westmead, and Associate Professor in the Faculty of Medicine at the University of Sydney.
And finally, we are also joined by Ted. Ted is joining us from WA today and is a Clinical Nurse Cardiac Rehab Specialist, with a career spanning 30 years predominantly in coronary care at the Royal Perth Hospital and collaboratively with Aboriginal Medical Services, the Derbarl Yerrigan Health Services and remote indigenous communities in Central Australia. So, welcome to all our presenters today and welcome to everyone who has joined us online as well. I am going to hand over to Cate now, and she will take us through our learning outcomes for this afternoon.
Cate: Thanks Sammi. By the end of this webinar activity, you should be able to identify the elements of cardiac rehabilitation programs and strategies to implement programs with Aboriginal communities. Identify those patients who would benefit from cardiac rehabilitation programs and review current referral and follow up with patients eligible for cardiac rehabilitation at their practice and develop strategies for enhanced rehabilitation support.
Sammi: Fantastic. And I will hand over to Raj now to kick off the start of our presentation. So over to you, Raj.
Raj: Thank you very much and welcome everyone joining in. I would like to thank the RACGP for the opportunity to talk about an area of cardiac care that is very, very dear to me for over 10 years now. I have set up a cardiac clinic at the Redfern Aboriginal Medical Service and see the acute presentations at Prince Alfred Hospital. I recognise about 10 years ago that the model of care had to change to get better outcomes in this particular cohort of patients, and hence the need for us to provide our cardiac screening clinic within the Aboriginal medical service, and really the missing piece of the puzzle is really cardiac rehabilitation and how to keep people well, rehabilitation from acute presentation and then improve their prognosis, and cardiac rehab and its staff and team that go with it provide a massive amount of resource and infrastructure to keep this happening.
So, I thought I would start by looking at a case. So this is a fairly typical case of a patient that I might see at Prince Alfred Hospital. So, if we start with a 50-year-old Aboriginal or Torres Strait Islander person who has had exertional chest pain. Sees you in the office for the first time and has complained of symptoms for two to three weeks, currently not breathless. We might have missed the most acute of the presentations, the worst of the chest pain was a couple of weeks ago, so we are really potentially dealing with a post-infarct situation which is not uncommon for someone’s first presentation. The patient is a smoker, he is obese. He has a family history of coronary artery disease and because of a lack of engagement in conventional care, he has not really be assessed for diabetes or cholesterol. So you note that the patient has a body mass index of 30 consistent with significant with significant obesity, both the blood pressure and the heart rate are elevated. Although there are no murmurs or anything unusual to hear in the chest, there are mild crepitations in both lung fields which starts to worry for the development of cardiac failure, especially if someone has had symptoms for two or three weeks where LV dysfunction can occur. From our point of view, time is myocardium and the longer these symptoms go, the worse the prognosis because the bigger the impact on the LV function. The cholesterol is noted to be 6 and the LDL is 4. So even in the best case scenario, being goals of an LDL 2.5, we would need this person to have a 20% to 30% reduction in cholesterol. We know that statin therapy is probably indicated in that kind of situation, as dietary modifications mainly make a 10% or 20% difference. And in someone who is having acute symptoms which are sounding very coronary, the trick here is that cholesterol levels are often lower because of intracellular recruitment of cholesterol, and so the blood levels of cholesterol can be artificially lower than what they had have been. So, if you had have measured the cholesterol six months ago, the LDL might have been 6. The blood sugar level is also elevated at 7.8. So we have got uncontrolled risk factors in a patient who has got acute sounding intermittent symptoms who has developed heart failure. Well, let us put these risk factors into context. When we are talking about Aboriginal and Torres Strait Islander people, all risk factors, it does not matter which one you look at, are over represented. And so on the panel on the left, the figure that you will see if you look at the levels of smoking, and this is from the last working group meeting to looking at the gap between indigenous and non-indigenous people, you can see the rates of smoking are very highly geared towards indigenous people. And then on the panel on the right, you can see in the pink boxes, the amount of patients who are overweight or obese is significantly elevated in the indigenous population. And this equates to what we call the “gap”. The gap is the mortality gap between indigenous and non-indigenous. So, if I go to the next slide, you will see that on the bottom panel, this is the gap represented in a figure. So if you look at the mortality levels of the non-indigenous group and the indigenous group, although there is a steady decline, it seems to almost be plateauing out over time. But we are not making significant inroads, which says to me that there is a problem with the model of care and hence the investment by us to deliver that care to within our Aboriginal services, but also within the community with cardiac rehab to provide that final step to ensure that all the good things that happen in hospital are actually carried out in the community and are resourced adequately.
This is the ECG of our patient who is experiencing these intermittent symptoms. In fact, while you have them in your GP office, this would be a very threatening ECG to find. What you will notice on this ECG is that the patient has an irregular rhythm. They have ST elevation in the inferior leads, that is lead 2 and 3 and AVF. There is reciprocal ST depression of a couple of millimetres in AVL and even in some of the anterior leads like V1 and V2. This indicates that this infarct is inferior, lateral and posterior. Remember the anterior leads can be the posterior leads but reciprocal changes. But importantly in the inferior leads there are Q-waves and this is consistent with the story that this has been going on for some time. A lot of her heart muscle is damaged and this leads to significant LV dysfunction.
So when the patient is seen by me from the GP’s office and emergency referral through the ambulance is made and the patient arrives now at Prince Alfred and we have a cardiac catheter where the catheter is seen as that long tube that arrives in the right coronary artery ostia. And then iodine is put down the artery and abruptly stops and there is no perfusion because of an acute thrombus within the artery. And then on the right panel you see that after the stent has been deployed and a balloon, that the artery is fully open and revascularised. That big “C” shape, so a lot of muscle. A big dominant right coronary artery supplying a massive amount of muscle.
So from our perspective, this is a typical patient who has had an acute coronary syndrome where the time to revascularise is the most important. The fact that these symptoms have been going on for a couple of weeks means that this patient has sustained significant myocardial injury. We have to make inpatient decisions about whether the patient is appropriate for stenting or coronary artery bypass grafting or medical management. These are acute decisions that we will make to ensure the best possible myocardial result and the patient will then end up on a number of prognostic medications, the anti-platelet drugs which can be multiple, aspirin clopidogrel, ticagrelor. Then the prognostic medication, such as statin therapy, aldosterone, antagonist ACE-inhibitors, ARB and now Entresto and beta-blockers, and multiple agents that we use. And this can often be an individual as I said in this case, a 50-year-old who really did not think he was unwell before and has just had a couple of weeks of chest pain and now has ended up with a stent, multiple blood thinners and multiple medications, all of which we know will improve his prognosis, reduce the chance of coronary disease progressing. But can we deliver those outcomes?
So the patient progress here is that the stent was deployed in the right coronary artery as a drug eluting stent. Most stents now are drug eluting stents because the rate of in-stent thrombosis is very low. The troponin peaked to about 5,000 nanograms. We may have missed the actual peak of course, because this may have happened a couple of weeks ago. In itself it represents a very large troponin rise and consistent with this, the echocardiogram shows moderate LV dysfunction. Injection fraction of 35% where the normal ejection fraction would be 55% or greater. Now the patient is on a bunch of medications. You will remember that the heart rate was 90 but now it is 60 and the blood pressure was 150 and now it is only 100. So you have got a patient who has low haemodynamics, mostly because of the prognostic medications that we are using, but is clinically in heart failure and intermittently in atrial fibrillation.
The next slide will show us an example of his chest x-ray, so you will see that there is cardiomegaly here. And there is diffuse increased interstitial markings consistent with cardiac failure. This was his initial presenting x-ray. And so he is in florid heart failure. To be at this level of cardiac failure, your level of cardiac coronary ischemia and LV dysfunction needs to be marked.
The next slide will show us the atrial fibrillation that he has developed. So you will see the ECG where the changes of ischemia have resolved, but he has developed atrial fibrillation. In fact on his presenting ECG he did have an irregular rhythm. And so we have two problems now where cardiac disease is now being complicated by cardiac failure but also by atrial fibrillation and the requirement for coronary stenting means that we have anti-platelet agents mandated but the development of atrial fibrillation in the context of LV dysfunction means that we need anti-thrombotic medications as well, which are our novel oral anti-coagulants, the warfarin. So multiple blood thinners in a young gentleman who has never really been on any tablets. So here are the tablets, the prognostic treatments which we know will make a big difference to this individual and that would be dual-antiplatelet therapies, aspirin and clopidogrel, or aspirin and ticagrelor. Now we are on apixaban, a third blood thinner 5 mg twice a day so the chance of bleeding is increasing. We are on beta-blocker, the carvedilol, the Entresto which covers our anti-neprilysin therapy as well as our ARP therapy, Rosuvastatin statin and Aldactone and Lasix. And at some point we may end up considering this patient for a device. Because if their injection fraction remains under 40% then the chance of sudden cardiac death, irrespective of the revascularisation remains and they may be considered for a defibrillator. So, big decisions for this patient who has had a life-changing moment.
So the goals for treatment here would be that we would be ideally trying to get this patient to under 130/80 blood pressure, a cholesterol less than 4, an LDL less than 2, optimal weight and blood sugar levels, and high exercise capacity. And really, from a cardiologists point of view, we want to see an increase in LV injection fraction over time because this determines prognosis. Patients are often obsessed by how many blockages they have, or how many that have had a quadruple bypass and five stents, and as I say to patients, it is water pipe to the garden. It is the garden that matters the most and it is about how well their heart functions that determines not just how long but how well you live.
Sammi: Awesome. Thanks Raj. So we are going to hand over to Cate now and then we will come back to this case study shortly. So, welcome Cate.
Cate: Great, thank you very much. I think Raj has very well set the platform of the burden of disease that Aboriginal and Torres Strait Islander people face and also their risk factor profile as well. So, I think the next slide basically highlights that heart disease is a lifelong condition and it needs ongoing management. And Raj has also identified that this gentleman now has a range of medications that he is on. He has had a diagnosis. He has had an intervention and I think the next slide, cardiac rehabilitation really should be a critical step in a heart patient’s journey. It really is an opportunity to provide the information about the new medications, what has happened to the person’s heart, what sort of changes they need to make to their lifestyle on a day to day basis. So it is really, really important that people do not leave hospital thinking that you know, they have been fixed, they have had their artery opened and that is all that needs to happen. They need ongoing management for the rest of their life.
Next slide. So one of the things the Heart Foundation has been doing now for some years also with the Australian Healthcare and Hospital Association has been running the Lighthouse Hospital project, and the aim of this is to really improve the health outcomes for Aboriginal and Torres Strait Islander people that present to hospitals with acute coronary syndrome, which is what Raj has just explained. So, the Lighthouse Hospital project has been funded by the Commonwealth Department of Health Indigenous Australians’ Health Program. And what it really aims to do is to achieve systematic change in the acute care sector, using a quality improvement approach and really to improve the outcomes. But not only the outcomes but to improve the experience of Aboriginal and Torres Strait Islander people and also to enhance the relationships and the coordination of care that is really vital between the hospital, the Aboriginal community controlled organisation and health services that actually work in the primary health networks.
So, as I mentioned it has been running for a number of years now and we are currently in phase 3. This phase has received quite significant funding which has been provided to the hospitals. The tool kit was developed in phase 2, so this phase 3 has been an opportunity to implement the tool kit and the other thing that has been really important is actually having local Aboriginal and Torres Strait Islander communities involved in the design, the delivery and the monitoring of the quality improvement activities. Currently there are 18 hospitals nationally that are actually participating and in New South Wales, we have the most amount of sites. We have five sites, Tamworth, Coffs Harbour that Joe is going to actually give us much more detail about, Liverpool Hospital, John Hunter and Orange Hospitals.
As I mentioned, the quality improvement toolkit basically focuses on four aspects or domains, care pathways which obviously is the opportunity to provide care along the patient journey. It is really important to focus on the workforce that is actually delivering the care, and building capacity and training staff. It is really important to have the governance right, basically to have leadership and accountability and staff that are actually providing the care to Aboriginal and Torres Strait Islander people. And most importantly to have cultural competency to basically have care that is delivered in a safe and culturally appropriate environment. You can see a screen shot of the tool kit that is available on the website, so I would encourage people if you have not had a chance to look at it, to go on it and have a look at the various domains and how the tool kit could be implemented.
So what I thought I would do would be just to give you a few examples of some of the successes of two of the hospitals, Liverpool and Tamworth, who were involved in the second phase of Lighthouse, and as a result of that, they have been able to develop formal links between Aboriginal Health, cardiology, the cardiac rehab services, and they developed a pathway for Aboriginal patients. They have been able to get an automatic referral to their Cardiac Ambulatory Services which is that they actually provide cardiac rehab and secondary prevention. They very much have been working with the Outreach Clinic and one of the things that they have been able to do as a result of the different services coming together, they have been able to provide five days of medication at discharge for patients that are actually enrolled in the Aboriginal Chronic Care program. So they have taken that sort of approach where they have tried to provide information, better coordination of care, and they are some of the successes that they have been able to have. And with Tamworth Hospital, one of the things that they have been able to do is to develop some culturally appropriate resources. They have developed a cardiac rehab booklet and they have the different members of the team who actually deliver cardiac rehab with a photo of them and what their role is in the delivery of cardiac rehab. They have also been able to develop some digital patient stories and they have involved their elders in some of the cardiac services to develop partnerships which has also been really quite effective as well.
This is just a couple of copies, screen shots of some of their cardiac rehab booklet, you know what they are aiming to do, what gets covered in cardiac rehab and this is actually provided to people before they leave hospital where appropriate and gives people an opportunity to sort of find out what will be covered to provide them with that really important ongoing management after they leave the hospital setting.
The Heart Foundation has also got some specific resources, both for health professionals and also for the patients, and one of the things that the Hear Foundation has done more recently is partner with St. Vincent’s Hospital Heart Health which is a specific website that is for, that has a lot of cardiac resources for Aboriginal people. I would encourage people if you have not had a look at it, to go on and have a look. They have a lot of animation. They have obviously got you know, information that is broken down into whether it is you know, to do with valves disease, whether it is a heart blockage. All the work that has been done has been co-designed with Aboriginal patients and it is very culturally appropriate. It is obviously pitched at a health literacy level which is appropriate as well, and they have a range of different videos. These two videos that you can see the screen shots for, Aunty Gloria’s story and her heart attack, and also her recovery, are two resources of a suite of four that were actually developed as part of the Better Cardiac Care for Aboriginal People, which is the National program. And these were developed also very closely with Aboriginal people’s input. So again, they demystify what happens if you call the ambulance and also try and demystify what actually happens when people participate in cardiac rehab. So I would encourage you to go on and have a look at those resources.
The Heart Foundation also has HEART Online. This is a whole lot of information validated tools to do specific assessments and whatever, so I would encourage you to go on. You may find something that may be useful in your practice on HEART Online. And we also have an online directory that allows health professionals and patients to find their local or their closest cardiac rehab and heart failure service. In New South Wales we do have several programs that are designed for Aboriginal patients. The Aunty Jean’s program which started in the Illawarra area has increased the reach and it is now available in some of the more southern sites in New South Wales. So again, go on, click your way around and be able to have a look. It is a great opportunity to see what is available for Aboriginal patients.
Sammi: Great, thanks Cate. We are going to jump back to Raj now.
Raj: Great, thank you. So, if we get back to this case, this person has now ended up on this trajectory. This is the trajectory of a patient with heart failure. And this is a relapsing, remitting condition where we achieve stability for periods of time and then we have periods of instability where we have LV dysfunction or coronary symptoms and you can see that the overall trajectory can be ending up with a palliative and a more end of life stage treatment. And our goal is really to keep people in the stable form of this disease, and we know that the number of hospitalisations and decompensation leads to people having poorer outcomes. So keeping people well in the community is our primary goal. So when you inherit these patients, you will note that they have several potential problems with the medications that they are on. You will note that by being on dual anti-platelets they can often have bleeding problems and the types of diuretic therapy that they are on can also lead to multiple problems as well. And so being able to target this is also very important from a patient perspective and so the goals of a cardiac rehab program will be to not just deal with these sort of symptoms but mostly to reduce the number of hospital admissions, increase their quality of life, decrease the number of symptoms they have which will ultimately reduce their morbidity and mortality and to be cost effective.
So we will skip to the next slide. At the first GP visit you will notice that these are all the potential problems that a patient might have, which is that, sorry if you go back one Sammi I will just talk about the symptoms there. So the patient can have light-headedness because of the number of drugs they are on. The statins may cause them muscle aches and pains. We have talked about the bleeding and the electrolyte problems. We can skip along two slides on from here.
The cardiac rehab allows us an opportunity to deal with these problems in a multidisciplinary way. And that is that cardiac rehab involves not just a clinical assessment, but also an ability to reinforce the importance of pharmacologic therapies and more importantly allow us to explore the non-pharmacologic therapies that might allow us to deliver the best outcomes. This importantly includes the opportunities for exercise training, counselling and education. And most of these cardiac rehab programs are very flexible to suit the patient. Next slide.
So, cardiac rehab has two phases. Obviously there is the in-hospital phase and that is coupled with the outpatient setting in phase 2. In the hospital the cardiologists are quite good at delivering the care, but there is a lot of things that we do not do and the gaps really from our point of view are dealing with things like depression and anxiety, to develop a proper chest pain action plan – what do I do when I leave hospital if I do develop some chest discomfort. Dealing with things like driving restrictions. Cardiac rehabilitation from a physical point of view, how much exercise, how much exercise, how often, how can I stay well? A lot of these issues are just simply not dealt with by the medical team. Whilst they are an inpatient, enrolment occurs usually in hospital, but if things happen at times of low availability of staff or weekends, then patients will be assessed and will be recruited in. So it does not matter when a patient has presented, they will be contacted and they will have an opportunity to enrol. Importantly the GP and the cardiologist are kept in the loop when patients consent. In phase 2 of our cardiac rehab program, we have an initial assessment and then we have an exercise program which is recommended. The initial assessment includes importantly not just physical but mental health and also a six minute walk test which ends up being one of the things that is presented as a pre-cardiac rehab compared to post-cardiac rehab outcome. And referrals are made to the other multidisciplinary teams that might be able to enhance compliance and improve outcomes. And often the medical team will not be able to reinforce these things and this is best done in the community. The most important of which are things like smoking cessation clinics, speaking to a dietician, psychologist, physiotherapist et cetera. Next slide.
You will see then that the exercise program can be incorporated into a My Health record, so patients can start to take ownership of their cardiac rehabilitation and also their cardiac condition. So they have the My Health program. The next slide will give you an idea of the risk factors and the outcomes relating to risk factors, patients being able to log on a monthly basis their outcomes, their physical activity, their compliance with medications, their own goals will really improve their compliance and allow them an opportunity to understand how much improvement they are actually achieving.
In the next slide you will see that the exercise program consists of a five or six week course. This allows patients to develop confidence in rebuilding their physical capacity. For some a regular exercise class was not something they were contributing to previously, so an opportunity to develop a program for themselves. Importantly, working on not just aerobic activity but light weights and endurance including the six minute walk test. These sorts of physical activity measures are very important and allow the patient a program that they can continue themselves. And when the patient has any type of problem, they have a hotline through to the cardiologist. I often have phone calls about unusual heart rate or symptoms during an exercise class and be able to deal with that at the time, and GPs are importantly kept in the loop. So for these patients, when they reach discharge from the cardiac rehab program, I am always given a letter which is sent also to the GP so that I can understand what they have achieved. Anyone who has dropped out of our programs are followed up intensely with phone calls and the GP and the cardiologist are also made aware of withdrawals. So the program is very comprehensive. I also think that the opportunity for patients to engage in activities with other patients who are experiencing similar problems really allows them to come to terms with what is often a watershed moment in their life when they have had their first acute coronary syndrome, and this provides both physical and mental rehabilitation for the patient in a very important way.
So the next slide. So, you know, in my final slide I am showing you that from a time of high risk where patients present in heart failure and have acute coronary syndrome, our goal is to shift everyone to the left and importantly in this step, the cardiac rehab program provides a very important opportunity to maintain physical outcomes, mental health is addressed, compliance of medications. And then our patient who is a 50-year-old gentleman who has had an acute coronary syndrome, complicated by atrial fibrillation and heart failure with low ejection fraction, probably of poor or low socioeconomic status and poor health literacy, cardiac rehab provides an enormous opportunity to engage this individual and to provide them with an opportunity to enable good health for the long term. Thank you very much.
Sammi: Thanks, Raj. So we are going to move on to Joe now, to his section of the presentation. So take it away, Joe.
Joe: Hi. So, the Lighthouse Hospital project at Coffs Harbour. My involvement started at the end of 2011 and in terms of the Lighthouse project as a whole and what we are doing here in Coffs Harbour, I will just give you a little bit of that before I jump into the slides. At Coffs, one of the main things we needed to do was increase the relationship with the AMS here in Coffs Harbour, Galambila. And that has come along very well. A cardiac nurse actually goes and participates in the monthly Healthy Heart clinic and at that heart clinic they have a range of other health professionals and also GPs. So Gps, cardiac nurse, Aboriginal health workers, dieticians, pharmacists involvement as well. So they get a good set of risk factors and they are identified and they also give management strategies, and one of those is to come across to the hospital for cardiac rehab. Also at Coffs Harbour Hospital, we have two great resources which were developed in phase 2 and one of them is a culturally safe educational resource for patients and it has got just basic information on anatomy that patients who have had a cardiac condition can go through with a health worker or a cardiac nurse. And also to compliment that, a flip chart was also made and that can help health professionals with a bit more in-depth information in that flip chart. There has been increased respect in the difference cultural awareness training in hospital. They have also developed some staff i.d. cards which identify staff if they chose to identify as being Aboriginal and it is like a little Aboriginal design on the i.d. cards. We are looking at starting hopefully soon an ED female Aboriginal Hospital Liaison Officer, and one of their roles will also be to follow any cardiac patients who present to ED on the patient journey through the hospital, so through ED onto the coronary care unit, up to the angio and then onto cardiac rehab. The angio unit has got some culturally specific and culturally safe discharge summaries. And there is also been two dedicated spaces in cardiac rehab for Aboriginal clients.
So, just to get started on the slide. Snapshot of Coffs. 5% of the population in Coffs Harbour identifies as Aboriginal or Torres Strait Islander. And 3.8% in Bellingen and 8.4% in Nambucca. And the cardiac rehab provides the opportunity for Aboriginal patients to attend those classes if they like. The cardiac rehab at Coffs is on a Wednesday afternoon for 3⅟₂ hours. There are two exercise groups and it runs for seven weeks. The exercise groups are circuit, so exercise bike, treadmill, upper limb strength. There is a mini-tramp. They can do some step ups, some arm ergo and we generally get all the patients to be monitored at a rate of perceived exertion. And the health staff at the class, there is two cardiac nurses and physiotherapists. There is also numerous students who come through the hospital such as nursing students and also physiotherapy students. During the education session, the cardiac nurse talks about risk factors and an overall of the heart and health. The physios talk about exercise. Dieticians will talk about what to eat. Social workers talk about getting control back and how some patients deal with losing like control of their feelings and have other learnings going on. Pharmacists will come and talk about medications and the occupational therapists talk about stress management and relaxation techniques.
On the next slide, I will just give you a quick overview of patients who have come to Coffs Harbour in 2018, so there was 377 referrals to cardiac rehab and only 28 of those were Aboriginal or Torres Strait Islander, so about 7.4%, and from that at Coffs Harbour, the next slide will show that the patient initiated phone calls to the cardiac nurses, there were 105 of those. The cardiac rehab called patients, so 79 and 133 letters were sent to patients and all the Aboriginal and Torres Strait Islander patients got called. So, the next slide shows how many people actually started and 82 of the patients who called up, turned up. And 42 of the phone calls from the nurses. Of the letters sent, only 15 out of that 133 so a big percentage did not attend. And again, of the Aboriginal and Torres Strait Islander only eight of the 28. So another area where it has not been the best. And completed rates, generally it is the patients that made the phone call themselves that had a greater chance of completing the session and the completion rate for those patients was about 75%. Of those cardiac rehab patients that were called by the cardiac rehab, 57% of those completed. And eight completed from the 15 that commenced with the letters, so that is about 53%. And only two of the eight Aboriginal and Torres Strait Islander patients actually completed the program. In terms of numbers, the cardiac rehab referrals in 2015 there were only actually 14 so just before I get onto the next one, there were only 14 in 2015, 12 in 2014, 31 in 2013. So overall of the percentage that has not been that many who have actually come through to the program.
Then on the next slide, they did miss a few patients and there was just no contact made, but that is okay. And in terms of no contact made, because one of the biggest things at Coffs Harbour is the staffing is one of the main barriers. Just not having adequate staffing to do enough phone calls and management of all these patients coming through.
The next slide just gives us a brief view of where the referrals all came from. So as you can see, there is quite a lot from the face to face in patient cardiac rehab nurses, which are doing their job. There are a good lot of referrals from the angio unit and also the coronary care unit. So there is another good area. And also down the bottom, the Galambila AMS had seven referrals themselves. So, and Aboriginal Health also had some extras. So that is a good sort of mix of where we have come from. The ones that are Cheryl who is a CNC for cardiac rehab, she always mentions how the patients who do call up are the ones more likely to complete their session and that has been very evident for me in the last year.
In the next slide we will just talk about some barriers. The referral pathway here at Coffs Harbour is a bit of a logistical nightmare. For phase 1 you need to put in an electronic medical referral but that is not always done and for phase 2 there is another process where we need to actually fax a referral across to an intake centre and then they send it back to the cardiac rehab nurses. And what we have found is the interns actually are so confused about which ones they need to send through to phase 1 and also phase 2 that in the end they do not always necessarily do that as well. So that is another issue. The parking at Coffs Harbour. There is a cost involved, so some people do not like having to pay for parking. Another barrier is the time of day. The afternoon class is not suitable for parents of young children and other times they are on school pick up and they miss the education component because it does not finish till about 3, so what if people need to go and pick up small children? And also, there is the second exercise group, if you participate in that you are unable to get the community transport here in Coffs Harbour. So they finish at 4, and they will not necessarily wait for you to finish your session so they will be gone and those people miss out in that one as well. Another transport issue is the bus timetable. There is not the best public transport up here in Coffs Harbour. So some patients do actually wait for an hour and a half for a bus or are here for a long time before the classes. Another one is the access to the gym. Sorry I have jumped a few there. The format of the classes. Some people do not like coming in and being with one person, particularly the Aboriginal people find it very intimidating but also non-indigenous that you come into a whole room, there is all these people sort of watching you and you feel a bit isolated and a bit alone, so that is one area, but then other people do not like group exercise sessions, so the big groups they do not necessarily like and prefer a more one on one. Staffing I touched on earlier, there is just not actually enough cardiac nurses here at Coffs Harbour and that has been a problem for a while. There is just not enough funding for that. The other one is the phone assessments. There possibly could be more than just getting phone assessments from the referrals, getting the patients in and having a face to face. And a big one here is access to gym space. There is mainly one gym class or gym space and it is in the physio department but it is actually pretty booked out most of the time because there is also pulmonary rehab that is run in there and also exercise classes for osteoarthritis through the OACCP. Some of the enablers is again, is the opposite. It is the format of the class.
Some people actually like the group environment so they actually feel safe in numbers whereas others do not like that. Having an Aboriginal health worker who is available to come along to the classes if there are Aboriginal clients who need that extra support, so that has been very good. I mentioned earlier that there are dedicated places for Aboriginal patients in the classes so there are two set aside. So that has been a good thing, so it is easier for Aboriginal patients to come straight on and start. One of the enablers here is that we have got a great bunch of cardiac nurses who have been involved in cardiac rehab for a very long time and the patients definitely feel very comfortable. And I was speaking to an Aboriginal uncle of mine who has actually been coming out from about half an hour away driving himself up here to attend the classes and he was singing praise to the cardiac nurse here. And he just says they are wonderful and it makes it really, it is worth the drive. The AMS, the Galambila as I mentioned earlier, their Healthy Heart clinic is fantastic and I have been along to it a few times and they do a really good job of selling the cardiac rehab hospital. Sadly we just have not had that transfer of numbers from referrals to commencing and then to finishing.
One of the big enablers is the Lighthouse Hospital project and some of the stuff we have done here is really good in terms of making it more noticeable to the nurses on the cardiac ward and up in the angio unit and both of those places have fantastic nurses who are really driving that.
So if you go onto the next slide, we are possibly looking at increasing the class size, so that will be a trial of increasing the number in the cardiac rehab classes because currently there is only really enough space for about 150 or 160 of those 377 referrals right now. So even if we did have 100% attendance rate there is no place for the people to actually have the cardiac review. So that is an issue. And there is some talk of an Aboriginal only class but yes, that could be a little bit of a while off I feel. And that completes it all up here in Coffs Harbour for cardiac rehab.
Sammi: That is great, thanks so much Joe. We are going to move on to Ted now to shoot through the final part of the presentation. We will stay back five minutes to try and take some of your questions because we are a little behind. So through this next section any questions you have, if you want to start typing them through so that when we get through the next 10 minutes we can jump straight on to them. So I will hand over to Ted now to keep us moving along.
Ted: How are you going? My name is Ted. I work at Royal Perth Hospital. I am a cardiac rehab nurse and I also work with the Aboriginal Medical Service called Derbarl Yerrigan. The last 10 years we have been running an Aboriginal cardiac program down there. It started as a cardiac rehab program but has morphed more into a chronic disease program because Aboriginal people do not just have the heart disease, they have diabetes, high blood pressure, obesity and all the other things we know. I put that picture up there about equality because we have had quite a few of our potential patients when the doctor leaves, they say “what did he say?” Our doctors often say “oh yeah, we popped a stent in V1.” And to a lot of our Aboriginal patients V1 does not mean anything. So I have used a freeway system where V1 is the first off ramp going down our major freeway and in Perth that is called the Mitchell freeway. Sometimes you know, the doctors say they had a heart attack or even nurses, but a lot of patients do not understand the difference between angina and a heart attack, so I use the freeway system again and angina is five o’clock on the Mitchell freeway when all the cars are blocked up but they are still moving, so it is reduction of oxygen and blood supply, where an MI is a complete blockage where a semi-trailer has blocked off the freeway and it is one o’clock in the afternoon and it does not matter if you are the king or the queen, but you are not getting past.
Next slide please. This slide says if you want to treat me, well you need to be prepared to treat me differently. For the Aboriginal program it is important that you have a mentor. I met an Aboriginal lady in 2007 and she started pointing out the fact that of a lot of our Aboriginal patients, only about 5% were coming to cardiac rehab, whereas we had this really lovely flash gym up at the hospital where we were getting about 30% odd coming to cardiac rehab there of non-Aboriginal people but only 5% were Aboriginal. So, what happened they then suggested to me that the best way to offer an Aboriginal program is to have a community consultation and find out what their community actually wanted. So in 2007 we asked the community what they wanted and they said they wanted exercise and they wanted education but they did not want to go to the hospital. So then the challenge was to try and work out how we could do all that and provide all that at the Aboriginal Medical Service.
Next slide please. And then maybe skip that one. Next slide. So what we have done at the Aboriginal Medical Service, we have created… oh go back one, go back one slide. So what we have done is we have listened to what the community want and we have created a flexible program that has no end date. Go forward one. And the reason it has got no end date, is if you think of the West Coast Eagles, those guys there the coach does not give you a sample at the beginning of the season for two weeks and says “oh I will catch you at the Grand Final.” He gives them constant training throughout the season. So that is what we do in our program. Our program has no end date. So clients come in as often, for as short or as little as they like. So we have a chap here who came in with his wife today. He has been trying to lose weight and her blood pressure was 180 on no medication so we have been working with her going on medications and she has lost 2.5 kg in six months. They come in for about half an hour and then they go off, whereas other people stay the whole day. Community consultation is the absolute. I cannot emphasise how important that is. If you are looking at setting up a program. My DNA rate is 0% because people, the clients chose when they want to come. I have had a few patients, or I have had two patients who presented with being short of breath for the last three days. You feel their pulse and you realise that they have flipped into AF and you refer them onto GPM and that is because they trust us.
Next slide please. The important components. Is there a need? You need to have a mentor and you need to have community consultation because word of mouth is extremely important and that will get clients to come to the program. I can give out as many pamphlets and phone calls as you want but if a relative recommends it then they will come. If you are going to set up a program, do not call it a trial because Aboriginal people are sick of trials. And when I first went there, the first thing they asked me was how long are you here for? So I kept on saying I am here forever but they did not believe me so a lot of them sat back and watched and waited and eventually they joined the program. The other thing is, our program is every Thursday except for two or three weeks around Christmas. It is between 9 and 12.30. Some patients come at quarter past 8. Some patients stay till one o’clock but that is part of that flexibility.
Next slide please. The premise of the program is about giving Aboriginal people power and control back through choice and knowledge. The program principle is the “YEES” program where you spend a lot of time yarning, giving education, exercise and we check everybody’s vital signs as they come in. That gives you an opportunity to yarn with patients and often find out they have run out of pills a few days ago or find out why their sugars are high and gives the opportunity to exercise. The reason we want to give, one example was that – I am running out of time so I better not give too many examples – so when I first joined the program I had a bit of philosophy from the hospital whereas I do everything and in the hospital you know, you take someone’s sugars and you write down the numbers. But in our program, what we do is the clients do their own sugars and what I have found is that some of our clients can put in a strip about four different ways, but if they cannot do it with us then they are not likely to be able to do it at home. You will probably be able to read this a bit later on, but one of other key components to put first is that you need Aboriginal staff. We have today, we have three Aboriginal staff, an exercise physiologist, a dietician who is in the building who I am referring patients to and myself. Aboriginal staff are crucial. We have the tables, the male tables and female tables. We do exercise in a circle. We yarn in a circle. We do education in a circle. Trust is a big thing. If you say you are going to do something, you must do it otherwise clients from the past I guess I have a certain component of mistrust for us. Your staff need to listen to the Elders and learn how to yarn. And you will find quite a few clients do not know about clinical, social and management yarning yet which makes it hard for them to communicate properly with Aboriginal patients. We have our exercise bikes in a group. We go for a group walk. We do group weights. We provide morning tea and lunch. If anybody is ever starting a program, you want to start about March and never have it on a Monday or a Friday. Friday because it is funeral day and Monday because clients are often tired from the weekend. And always have them in the morning.
Next slide please. So the next slide talks about engaging and I think I have talked about that trust, being non-judgmental, being flexible. I give a lot of examples in pictorial images with my clients because they learn best from that. Listen to what is not said. God gave us two ears and two eyes, so he wants us to listen and watch more often than he wants us to speak. I could give you some good examples on that one. A lot of our clients have stress in their lives and the other thing is when you are trying to communicate with Aboriginal clients, send a text first. You and I do not answer blocked numbers for obvious reasons. Say it is Ted here from the cardiac rehab program. I am going to ring you in two minutes’ time could you please answer the phone.
Nest slide please. So there are some barriers. Transport like the other fellow from Coffs was saying. We have transport issues. So when you are setting up a program, it needs to be in a central location. Ours is close to the railway line, good bus access, free bus access, but you still rely on transport. Last month, 30% of our clients were brought in with Aboriginal Medical Service transport and the rest made their own transport in the best way they could. Communicating - we talked about mobile phones there. Funding is a big issue, please do not set up a program if you do not have secure funding because it just makes it harder for the next person to try and set up a program and also it destroys the trust that you develop with the Aboriginal patients.
Next slide. In this slide we talk about some of the results. We definitely are getting better sugars. Our sugars are under 10 now. We have one lady last year who said this is the first time, the first year in her life when she has never actually had to go to hospital. We are getting weight loss. It is a gradual weight loss, it is not rapid. Our clients will know when to go to hospital and they will come and find me if they are at AMS and they are unsure about things. And because we have a trust and rapport and relationship, they are more likely to actually ask you the questions that they will not ask other people.
Next slide please. And then skip that one. So the next one. So if there is anybody out there with influence, if you look at the Aboriginal care plans that the GPs fill out, you will notice that there is no cardiac rehab on that. If there is no cardiac rehab, that makes funding extremely difficult and that is just crazy. So I have brought this up with the Heart Foundation to try and support this. You can see I got referral for an exercise physiologist.
Next slide please. So, the hot spots and we are working at Royal Perth, also at Lighthouse, is the Kimberley and the Pilbara. There is minimal cardiac rehab services out there and as a result in these angina hot spots when we need to get better education not only in the hospital but we need to find other creative ways. And in the Lighthouse program we have now got visiting cardiologists to the Kimberley and now at Royal Perth we refer to them clients travelling 2,500 km to Royal Perth for a 15 minute appointment. So we are getting better attendance also up in the Kimberley. They know when there are funerals so they are more likely to be able to work around attendance.
And next slide. I am almost finished. Next slide please. So this one here is in January. The bit I find quite shocking here is that if you look at the graph on the left, 61% of the Aboriginal and Torres Strait Islanders were under the age of 60. That was female. So 72% of males are under the age of 60 and that is crazy. The other breakdown is I think you can look for yourself. Aboriginal women come here you know a good 20 years earlier than everybody else. We are making a difference and closing the gap. Average age is now down to about 13 years.
Next slide. I do some cardiac rehab out near Warburton as well as in the city as well as in the Aboriginal Medical Service and that requires us to be quite creative with our teaching and the cardiologists doing their tests as well.
And the last slide. Just a little bit of a conclusion for those, there. We need to provide a culturally safe with Aboriginal staff if you want to have a program that is, the program needs to be at the Aboriginal Medical Service or where the community says that they would like it to be. You need to consultation with the community about what time they want it, what day they want it, how long they want it. It is really important for us non-Aboriginal people to have an Aboriginal mentor, someone to guide you through. Someone who is leak-proof, that whatever you talk to that person about it will not go out into the community, otherwise your program will close overnight. We need to have someone who can teach us about Aboriginal culture and can help us and guide us through to provide Aboriginal people with better care.
Sammi: So we have just got some links up here on the screen where you can go for further information and resources, so we will send a copy of this presentation around to everybody as well. I did have one question for Joe that had come through in regards to the Coffs program. Someone asking if it is only offered once a week, Joe?
Joe: Yes, currently it is.
Sammi: No problem.
Joe: Previously, firstly there was an education part but that had to be cancelled again due to staffing issues.
Sammi: No problem, thanks very much. Alrighty, so there are only two other questions that have come through and they are quite specific, so we might get back to those two participants off line. I would like to thank everybody who has joined us this afternoon and our presenters as well of course. Up on your screen now is a review of the learning outcomes that Cate took you over at the start of the session, so we hope that now at the end of this activity, you are able to do these things better and have a little bit more understanding and are more confident. So in saying that, that does bring us to the end of the session. We are sorry we have run a couple of minutes over time so we will let you get back to your days. So thank you very much to our presenters again and everybody online.