Daniela: Welcome to the I Can See Clearly Now, Good Experiences and Great Health Outcomes through Effective Country Safe Primary Health Care Webinar series, and the second webinar, which is the case study about working together to achieve great health outcomes.
To begin, we recognize the traditional custodians of the lands and seas on which we live and work, and we pay our respects to Elders, past and present.
As per the first webinar, today's presenters are Dr Mary Belfrage who is a medical advisor on the RACGP-NACCHO Partnership Project and a general practitioner. Mary has been a medical practitioner for thirty years. She has worked as a GP in community health and in Aboriginal community settings in both desert Aboriginal communities and, from 2009-2017, as the Medical Director at the Victorian Aboriginal Health Service in Melbourne. Mary has been involved for many years in teaching medical students and GP registrars about working effectively with Aboriginal patients and communities. She has also been involved in numerous research projects and held policy and clinical advisory roles in wide-ranging areas including primary care, population health, effectiveness and acceptability of models of healthcare, and safety and quality of healthcare. Mary was an author of a chapter in the latest edition of the National Guide to a preventive health assessment for Aboriginal and Torres Strait Islander people and was the Clinical Lead on the RACGP-NACCHO project to review and develop new recommendations for the MBS Item 715 annual health check for Aboriginal and Torres Strait Islander people.
We're also lucky tonight to be joined by Ms Jacinta McKenzie, who's an integrated team care supervisor, Indigenous health project officer with Wellness our Way at Country and Outback Health. Jacinta has 20 years of significant experience working across many communities, primarily working on the complementary project to support collaborations in the Aboriginal primary healthcare, and mainstream GP practices. She has been a project group member of the NACCHO & RACGP reference group to support Implementing the National Guide and supporting mainstream general practices to deliver culturally targeted and responsive healthcare for Aboriginal and Torres Strait Islander people she is also a member of the 715 Aboriginal Health Assessment Project Working Group.
As a leader Jacinta has a vision to inspire her community to motivate change and support culturally safe practices and is determined to build partnerships that support equality and good health care outcomes. Jacinta’s vision is to embed cultural safety by strengthen the pathways from the patient centred care perspective and explore the strengths of integrating cultural mentorship to care planning and follow-up care in the community.
And last but most surely not least, is Ms Ada Perry. Ada is a cultural and education advisor with the RACGP faculty of Aboriginal and Torres Strait Islander Health. Ada is a Brinkin woman, a grandmother of 12, and her languages are Marrithiel-Nganghikurrungurr.
Ada has a long standing relationship with the RACGP from being a cultural educator (of medical students and GP registrars) from 1996 to 2000 and a community representative on the RACGP Aboriginal and Torres Strait Islander Health faculty Council in 2015. In 2018, Ada took on the role of Cultural and Education Advisor with the RACGP Faculty of Aboriginal and Torres Strait Islander health and is heavily involved in all areas of operation ranging from education and training, and policy and advocacy.
And now Dr Mary Belfrage will start the webinar.
Mary: Thanks Daniela and welcome to everyone. Thank you to everyone for accommodating a change of date for this webinar. Of course, COVID has demanded a lot of attention from all of us, and actually, some of us have been involved in development of recommendations for the Aboriginal Torres Strait Islander primary care where there are gaps in guidelines.
By the way, this collaboration with NACCHO, the national peak body of Aboriginal health services, Lowitja Institute and the Australian National University, has developed these recommendations, which went live yesterday. The first of which went live yesterday and are available on the NACCHO website.
OK, so, this is the second of three webinars about achieving great health outcomes in general, practice for Aboriginal and Torres Strait Islander patients. In the first webinar, we talked about some of the principles underpinning culturally safe healthcare and explored the RACGP-NACCHO Resource Hub, which is housed on the college website.
In this webinar, we're developing some of those same themes and hope to deepen your knowledge and understanding of what it takes to provide culturally safe health care and to recognize some of the barriers to healthcare Aboriginal and Torres Strait Islander commonly experience. We'll demonstrate the application of some of these key themes, and offer some practical ways to work effectively with great outcomes through the case study that we're going to present.
In the third and final, webinar of the series, which is on next month, we'll be looking particularly at useful, high quality annual health checks for Aboriginal and Torres Strait Islander people, and where sit within broader primary health care.
Jacinta: The voice represents some of the comments that can affect engagement.
Many of you may have had similar situations with complex clients and can relate to this story.
Jenny is a middle aged Aboriginal woman with complex health and social needs. She spend all day, trying to reach out to services, hoping that someone will give her some time just to listen. She needed help and Jenny was at a breaking point.
Jenny reached out to a variety of services, and every service she contacted asked her to make an appointment or mentioned they I couldn't help her. She felt rejected, so she went to a community mental health service asking for help. A representative stated to Jenny that they couldn't help her because she didn't have a goal. Jenny stated “My goal is to survive”.
So they brushed her off and referred her to a local Aboriginal Health Service as she was getting nowhere. Jenny was referred to an Aboriginal worker in a mainstream community mental health service, and with Jenny, this was her last service of hope. Jenny presented at this services and stated “I have nowhere else to go. I've been everywhere.” The service recognised that she was agitated, distressed, upset and anxious. She asked speak to an Aboriginal worker about her story as she felt hopeless as stated that no one cares. Jenny was invited to speak to an Aboriginal worker who was part of the Integrated Team Care known as ITC.
This is where Jenny's journey started.
Mary: This experience of going to lots of services and not getting good health care, not really engaging or not landing there, is common. People described feeling judged and rejected of getting a clear message that they're not a good fit for the service. Sometimes this is about specific eligibility or ineligibility criteria. Sometimes it's about not feeling welcome or safe.
Sometimes it's about not being offered services that match what the person is seeking. Sometimes it is frank racism, as in this service isn't for you and there's an Aboriginal Health Service down the road….and sometimes the intentions are good, but they still miss the mark.
Ada, do you want to say any more about this?
Ada: Yes, I wanted to say that, you know sometimes for our people it's uncomfortable walking into a place of unknown. But, the story is out there for our people, in amongst the Aboriginal community, where community services are available or not, and it either makes it harder or easier for our mob to attend. It's about making people comfortable when they come to your services and making them feel welcome.
Jacinta: Thanks, Ada.
So, it's important to understand the impacts of inter-generational trauma. This is linked to many Aboriginal Torres Strait Islander people’s experiences. So be gentle and show you some empathy.
Then moving forward to the safe space. This was important for Jenny as she needed to feel that she had privacy and a space to talk openly with dignity, and where she wasn't going to be judged. The Aboriginal worker, just to let you know, had a Stay Safe app on her mobile, just so that she was safe when she was talking to Jenny. She mentioned to Jenny, she had some time to yarn and talk to see if Jenny was OK. Jenny stated that she was feeling angry and express suicidal ideations. The Aboriginal worker listened to Jenny, as she was opening up. This was the most important step.
When Jenny was calm, the worker was able to ask questions that weren’t intrusive. She just needed to work in a way that identified her needs, including eligibility for services. This was Jenny's last place of hope. It was important that Jenny fit the criteria somehow, and if she didn't have a chronic disease, she wasn't eligible to access ITC program. So we had to make sure that the criteria was for Jenny, and this is where the next stage for culturally safe healthcare began for Jenny as we continue to share her story.
Mary: Yeah the striking thing is how Jenny responded to the care that was offered. The care that was taken, that there was some Aboriginal worker available. So that was the Integrated Team Care Aboriginal outreach worker. That people took the time to listen and tune in, and weren’t rushing, to check whether or not she was eligible for services.
So Ada want to say a bit more about why that makes a difference and I think, also what if there isn't an Aboriginal worker or staff member? What are the things that make a difference to an Aboriginal person feeling welcome and safe?
Ada: I think for me, it's taking the time to listen and showing empathy. It really makes a lot of difference for people who are new to your clinic, um, and it makes the person feel worthwhile and valued when someone spends a bit of time with them.
Mary: How much of a difference does it make if, you know, for a lot of GPs, there's not always going to be an Aboriginal worker available?
Ada: Well, I think, you know, a lot of people who become doctors, in the beginning, they want to help people. I think, that helping people shouldn’t go out the window when it comes to Aboriginal people or other people that aren’t from your cultural background.
Mary: I've always found, even when there isn't an Aboriginal person who's part of the healthcare team, that, if I'm listening carefully and respectful and kind, that the consultation will usually go very well and people are likely to come back.
Ada: Sure does Mary. Especially when people are empathetic who probably don't know anything about medical stuff, but having someone talk to them in a gentle way makes a lot of difference.
Mary: Ok, let’s keep going with Jenny.
Jacinta: Finding a GP. As you can understand, a client might have their file at a few destinations. So their medical history and relevant medical information can be hard to gather and this can be difficult when assessing client. In this case, the Aboriginal worker asked Jenny which doctor she wanted to see? She couldn't remember the doctor but she remembered the practice.
The worker managed to get an urgent appointment with a GP that Jenny had contact with in the past. The worker also Spoke to Jenny about another worker providing support. So there were two workers with her, which can be too much, but in this case this was OK.
The worker recognised that Jenny's healthcare needs and mental health was a priority. There were workers transporting Jenny to your appointment, as she had no means of transport. You might hear the term “Walkabout Ford Falcon” or “no mooticar, meaning “no car”, using a sense of humour during hard times. Just to share a moment the car, one of the workers mentioned “it's a nice day today” and Jenny replied “Who cares about the day?”. The worker new this was a case of listening, and that was the key.
The next steps into the practice was again important. The receptionists was welcoming and calm, acknowledge Jenny and guided her to a safe space waiting for the GP. The GP invited Jenny into her area she spoke to Jenny with respect, empathy and focused on listening whilst Jenny expressed her worries without being cut off or judged. The GP assessed Jenny’s a mental health. This was vital to stabilizing Jenny. After this consult, the worker transported Jenny to the pharmacy to get her medications sorted. She was signed up for Closing the Gap for prescription as Jenny had no “bunda” meaning money.
Mary: I think you made the important things in that the Aboriginal outreach worker knew what was needed and knew how to navigate the system, which not all patients feel confident towing. So Aboriginal outreach worker was able to get the urgent appointment. The practice was welcomed.
Once in the practice, for a patient like Jenny, it’s important not reflecting the chaos and causes of the patient and to take time and to identify clear priorities that are in tune with the patient needs so not to overwhelm the patient by trying to do too much. Which is, I think, a real trap when you do establish a connection and you’re wanting to do something useful for the person, there's a temptation to do too much. That sort of being opportunistic, which is part of our training and what we're on the lookout for.
It can be experienced as overwhelming for the patient that sort of pouncing on people and the “I'm trying to do healthcare to them”, can scare people off? It's definitely one of the issues for junior doctors and junior GPs, just to encourage them to tamper their enthusiasm and not try and do too much, but rather focus on establishing a relationship an trust, and just doing a little bit, e.g. making the next appointment.
Ada, do you want to say a bit more about what helps people to feel safe and to engage with the GP.
Ada: I think as a starting point for the GP to make small talk, getting to know the patient by ice-breaking questions and think about what that person has come in for today, not what you're thinking about such as why did they come in, and what it feels like for your patients to come into your clinic today? Is it easy for an Aboriginal person to come in today? It may have been not so easy. At the same time look after you as the GP and pacing yourself with that patient. A acknowledge what the patient has come in for, the responsibilities she might have and the responsibilities you might have. We as Aboriginal people, don’t come in alone and we come with all our baggage, and some of you may have experienced that because maybe of conversations with your friends or your patients, but you have to keep that in mind.
Jacinta: Thanks Ada.
So moving to Jenny and her healthcare team work.
Jenny's knowledge, understanding and accessing healthcare was limited. Therefore, planning her care was key to support a build a knowledge network. So over a period of six months, Jenny had weekly appointments with her GP and also a regular contact with the practice nurse.
It's important to highlight that for the weekly appointments to work for Jenny, they needed to be scheduled by Jenny. Her time but fitting into the practice times of availability that was close to her request. So the same time each week was scheduled, and the Practice Nurse and Aboriginal Worker made reminder calls a day before to keep Jenny engaged. This was important.
As you can see in this section, health were needs identified, some of the complexities around Jenny's health and well-being is a lot for Jenny to be trying to manage, considering a mental health. It was important to help Jenny on the right track, and look after health better. She had significant health issues. She's a smoker of cigarettes, and yarndi, meaning marijuana, and loves drinking (not water by the way).
I would also like to feedback, Jenny’s support system with the health system and Aboriginal Workers supported her engagement in returning for health care. Information provided to Jenny was clear, and her health needs were planned according to Jenny. Jenny taking control of her health her way. So moving forward into parts of the 715 of Aboriginal health check. This assessment was not in order but was broken up to different stages in a weekly consult at Jenny’s pace, a question was put to Jenny by the GP about her physical activity (as she was a bit overweight), Jenny stated “I walk to the letter box and that’s it
The GP’s replied with “maybe walk a bit more, around the block”. Jenny replied “if it’s not cold”. The GP responded with “put a jumper on just try and walk that’s all I’m asking and its good for our health”. So maybe another suggestion is walk in warmer weather because this fits Jenny. We all know how this feels, we think about it and at times even we feel the weather impacts our choices. So Jenny you’re not alone. The remaining appointments were scheduled around the 715 women’s health check, dental, biomedical, referrals to allied health. The appointments were purposeful, and a lot of planning and team care arrangements went in to supporting a complex case. 28:05
Thanks Mary.
Mary: Do you want to say a bit more about the different aspects of her care?
Jacinta: As you can see in the four boxes, her care was co-ordinated in this approach, it wasn't always in order and everything went according to Jenny and when Jenny was available.
As you can see, in the first box we have the ITC Registered Nurse for care co-ordination who provided support and access to navigate all the other areas similar. From the 715 health assessment, the referral pathways into the other areas was quite important.
Jenny needed a lot of advocacy with regards to what that pathway look like because a piece of paper and a contact number wasn't good enough for Jenny. So we had to make sure that we used appropriate forms in regards to accessing allied health and looking at how we can report back in regards to summarizing all the steps and the pathways that Jenny had accessed in order to keep up to date with her case.
So as you can see a lot of allied health access and after 715 health check there is free access to those areas, and d Jenny had made sure should access. Her most important access will see optometrists and her list. But it's important to also note that looking after her mental health, we had to make sure it was culturally appropriate in the different stages. So, the narrative therapy and social emotional well-being groups also provided Jenny with some strength. So that's what helped Jenny stay strong within her case.
Thanks Mary.
Mary: Thank you.
I think the key feature here is the approach to better health care is built on doing everything together but also working in partnership and supporting Jenny’s agency, and this is the foundational principle of trauma informed care. Recognizing trauma, a bedrock issue for people like Jenny is important. This cascade effect on physical health and social emotional well-being and mental health that presents in exactly this way with complex medical and social needs. And at the end of the presentation, which you'll have access to, there are some resources that are around trauma informed care, but these, in my experience, Jenny’s mix of the medical complexity and social complexity is common.
So, given this complexity, actually despite this complexity, the complexity of Jenny’s healthcare needs, the approach is planned and well organized and each step is negotiators and happens at a pace that works for Jenny.
It's a real challenge in all this complexity to not be overwhelmed as a clinician. It's so easy to be busy, but not effective. And I think this is one of our high level clinical skills as a GP. One that I always felt was a key learning for GP registrars who did placements with us, that challenge of being organized within a consultation with someone who presents with often in crisis and with lots of complexity. Then, too, as well as the individual consultations, tend to have a meaningful Plan that actually supports good health outcomes for people over time.
Having an Aboriginal worker is gold. It builds trust and confidence for the patient in what is being offered and allows understanding and communication to be checked in in both directions, in two ways for the clinician and for the patient, and it really paves the way for a GP for the services in a way that is useful and effective.
Ada, do you want to say, a bit, about having, an Aboriginal health worker, Aboriginal staff member in the, in the health care team and in the consultation.
Ada: Thanks Mary.
If you do have an Aboriginal person working in your clinic, make sure you make use of that person, because that person is not only there for the doctor and the clinic staff. She's there to pave the way or he’s there to pave the way for the patient, at working and understanding and learning. And even if you don’t, you're the doctor and you're the one that's made the choice to work with people from the public. You can do it on your own as well. You know your business and that Aboriginal person, if you've got one, knows their business, so you can together you can make it work.
Mary/Jacinta: Thanks Ada
Jacinta: So Jenny and her health care team. I just wanted to touch base on Jenny. Jenny and an Aboriginal worker went for an eye assessment. Jenny wanted bling. What's a pair of glasses without bling? Well in this case, the bling had to be at a cost, and the worker stated “You need a lens more than the bling.” Jenny laughed. Jenny stated she couldn't afford, so access to ITC Supplementary Services provided support as she was registered with the ITC and is this access wasn’t going to work, she was going to explore the Native Title Group with support of some medical aides.
The next appointment, the GP had to give Jenny her Depo, noticing improvements so she asked Jenny how her lifestyle is. Jenny described the complexities around this, which I'm sure the GP was thinking where to start, but in Jenny’s day-to-day life, this is normal, overcrowding and family problems. So the GP let us speak openly and Jenny asked the GP if she had a cleaner. This opened the conversation more, but funny enough the GP had no comment and smiled.
The GP had one last question in the consult, a section around activity, so you’re probably wondering what activity? This was a sensitive topic relating to a sexual health conversations. Jenny looked up to the ceiling, looked at the doctor, the doctor looked at the Aboriginal worker and then Jenny out aloud stated “Nah I don’t touch my man” so you know where this conversation went, the box was ticked but it was followed up sensitively.
I just want to mention, as well, that the weekly appointments continued, her mental health care plan was addressed and the 715 Aboriginal Health Check was completed in stages of six months. The ITC care arrangements was up for review and the practice nurse followed up with two weekly DEPO for psych injections and co-ordination of care with ITC for Pathology, Allied Health appointments, and recalls. The medication review was also part of this and Jenny’s care was followed through.
Information was provided to Jenny by the pharmacy as she wasn't eligible QUMAX (Quality Use of Medicine, Home Medication Review etc.) so the pharmacy provide extra support with her Webster Pac.
It’s important to access the Integrated Team Care Teams across your area as the care coordination and outreach worker supports assist the journeys and supports access to health care. The ITC workers also have a project officer who can support your practice with Closing the Gap initiatives, Cultural Endorsements Programs to support Welcoming Environments and Cultural Awareness training to build knowledge and support culturally appropriate health care. This program comes under your PHN. I would also like to share with you that Jenny’s glasses were ready in 2 weeks and the Aboriginal Worker had to drop the glasses off to her. Jenny was outside her home smoking so the worker reminded remained inside. The glasses were provided to Jenny and Jenny embraced the worker and stated “I can see clearly now the rain has gone, I can see all obstacles in my way”. She also stated “I’ll be going away for Christmas”. This was also important for Jenny as we had to set up for Jenny. Jenny’s emergency support was organised, and she decided to go back to country (her homelands, for healing and to be grounded on country) she saw a Ngangkari (known as a traditional healer) and spent time with family. Over to you Mary.
Mary: Thanks Jay.
So there's a whole lot of that’s working really well for Jenny and we'll come back to her story. But, just want to do a bit of housekeeping and to remind people how all these services are funded. There's a whole lot that is funded through the MBS. The general time based consults, the extent of primary care items such as care plans and reviews, the 10 care arrangements, case conferencing, medication review, Aboriginal and Torres Strait Islanders specific items, but particularly the health checks – 715 and 228, and now in this COVID era, the telehealth based items. Also, follow up items that are facilitated by completion of a health check that can be done by practice nurses and Aboriginal health workers.
There’s also allied health services, although that's limited MBAs reimbursement and doesn't cover the cost of private allied health services such as mental health services for the better access initiative, and medications which some, since 2010 has been funded through the PBS co-payment arrangement, commonly called the CTG or Closed the Gap Arrangement.
There's also the other services that Integrated Team Care (ITC) program provides. Every PHA is funded to administer the ITC services, as well as the Advocacy and Support Services that can provide transport and equipment and co-payments as Jenny experienced. And then there are other local government services that may be available. The local Aboriginal Health Services may provide some services into Aboriginal and Torres Strait Islander people who aren't attending those services that varies regionally, so really need to check on the details of what services are available locally.
I think I didn't mention the Indigenous Health Incentive for accredited practices, with fairly substantial registration and then tier 1 and 2 outcome payments to remunerate the provision of complex care, like the sort of care about people like Jenny need.
OK, so back to Jenny.
Jacinta: So Jenny, today, she’s had her 715 health check and mental health care plan completed. Intensive care co-ordination for a period of six months and now she’s in the low category for follow-up.
Jenny is independently accessing health care herself. She has a better understanding of health care and she has better relationships with some family members, her immediate family members. There's improvement in health literacy, so she's understanding each component of her health care needs. She has information relating to health and she has primary contacts. She has direct contact with her GP, so there's no more juggling different services. She has one main contact, and that's her GP looking after her care.
Jenny, previously wasn't engaged in health care at all, but as you can see now she is. Jenny only calls the ITC Worker, the Aboriginal worker to get some taxi voucher and this is to support her to get her appointments. This is leading toward supporting her independence. The ITC worker no longer attends her appointments as Jenny attends with her partner. She attends Women’s Groups, Tobacco Awareness Groups, and has more contact with family and looks after her nieces and nephews. She has gained trust within her again with family and has better relationships. She has a regular Depo, and she has never missed any to date. Jenny’s mental health is stable. She does have her up and down days and will seek help at the right service she can rely on for support.
There isn't a guarantee that things are smooth, and this is a case where it's stabilized. That's what matters. She has control over her life and manages the best way she can that suits Jenny. She receives a Webster Pac for medication management, and the Aboriginal worker noticed Jenny has more motivation and seems at ease and she's communicating really respectfully.
The ITC program provides chronic disease management support, according to her GPMP aiming toward self-management. This support for travel to specialist appointments to the city as a clear travel plan and ITC supports travel and access to pets. Jan is self-managing, and she's not demanding the services. She is spending a lot of time with the Elders and socializing with the women's group as a support network, yarning up about cancer and other preventative health issues and is supported by women in that group.
Jenny will be discharged from the ITC program soon and the Aboriginal worker had permission to do an evaluation and asked her ‘are you happy’. This was completed and she was happy with all the services.
Over to you Mary.
Mary: I think it's up to you to share Jenny's most positive moments
Jacinta: So Jenny’s most positive moment was when the Aboriginal worker gave Jenny her glasses. In a case Jenny opened it up with a smile. She tried the glasses on and the words that came out of their mouth was “I can see clearly now the rain has gone”. Jenny gave the Aboriginal worker a hug and said thank you. She then continued to walk back to a house singing “I can see all obstacles in my way”
Mary: Thanks Jay. This is such a good story of great outcomes. This is a patient who started the journey with a lot of complex needs and no confidence that anyone would or possibly could help her. She was supported firstly to engage and slowly to take control of her health and health care. She had strong support from the Aboriginal Outreach worker, which was really important in practical ways, getting her into the practice, and especially initially in building cultural safety and trust. But that way of working wasn't about building dependency, it was really about building her agency. Then there was a whole of practice commitment to continuity of care to being responsive and kind and flexible. So, rather than finding her too hard to sort of heart sink feeling that we can feel with very complex patients that can feel hopeless. This was actually a rewarding experience for the practice team as well as obviously good. for Jenny.
Do you want to add to that Ada?
Ada: I just wanted to say a true partnership for you as a GP, is with your staff and your patients, and being able to depend on one another to do a good job. From the receptionist, to the Aboriginal worker, to the GA, everyone knowing what is expected when the patient comes to the clinic.
Mary: As we finish up, we just want to share a couple of slides that outline some of the high level and relevant principles to working effectively in health care with Aboriginal and Torres Strait Islander peoples. These slides I'm not going to go through them in detail, but you'll have access to the presentation on these will be available for your consideration. So, this one, as it states, is about social and emotional well-being.
These principles, which were first described by Pat Swan and Beverley Raphael, in 1995 in a fairly landmark report, have been continued to be used to inform the guiding principles for the national strategic framework for Aboriginal and Torres Strait Islander People's mental health and social emotional well-being, 2017 to 2123, and we've got a link to that in the resources page. Then the other slide is the distillation of my reflections over many years in clinical practice and as a teacher, the teacher, and mentor, and the program and policy advisory roles, some of key to themes or elements that are important in terms of working effectively in Aboriginal health. We could not happily talk in detail about all or any of these, but for those of you who like a framework and think in principles, I thought this might be a useful bird's eye view. In the resources there are some links to different aspects. Firstly for the resources, these are the college resources, the first one, the Resource Hub, has got a whole range of resources and we’ve been be looking at some of those. We did in the first webinar, and will revisit that in the third webinar which will have the focus on health checks, but also the National guide to preventive health assessment for Aboriginal and Torres Strait Islander people. Some of the other resources that the college has, then some other resources around trauma informed care, and identification and cultural safety.
Finally we're happy to take questions.
Daniela: Thank you, Mary and the presenters.
We do have a couple of questions, I think would be lovely to get to “We have my experience is that an Aboriginal patient comes to see GP. It's easy to manage the acute conditions or acute on chronic conditions, but ongoing condition management, and preventative care is very difficult. Do you have any comments and, or any suggestions on what one can do in that space?
Jacinta: I was just going to mention access your local PH, an integrated team care for chronic disease support management and care co-ordination, and they have access to outreach workers in the area.
Mary: I think wondering about the timing of that question, because I think that's partly what we've been talking about tonight. I think that the really essential component of being able to work effectively in the long term, is about establishing an effective therapeutic relationship. So establishing trust, and hopefully some of what we've presented tonight helps you to think about how you do that. But I think establishing trust, I'm working at a pace that’s in tune with the patient, acknowledging the context of that person's life, and all the things that are going on for them is really important. understanding what the, sort of what I call, those sort of bedrock issues, I think it's just so common, form many Aboriginal people, the impact of trauma is huge, and that's not the reverberation of invasion of colonization and the way that cascades down through generations. The individual experience of the patient in consultation with you, what their personal experiences is as well, and I think understanding for people with very complex medical and social needs, having an understanding of trauma is really key, and I encourage people to look at the Healing Foundation and the Blue Notch Trauma informed guidelines.
Daniela: Thank you Mary. We’ve got a question here that mentions “Making complex team care plans for patients, sometimes the GP can maybe feel overwhelmed or overwhelm the patient. Would you have any suggestions or handy hints on how to avoid the patient becoming overwhelmed with the complexity of the planning?
Mary: I think it's a really key question.
Really tests our clinical skills in a particular way. I think as I described to it's so easy to be busy, you’re not effective. It's so easy to reflect the crisis and anguish, and chaos that people can present with. When I was the Clinical Director at the Victorian Aboriginal Health Service, it was one of the things I talked to talk with staff a lot about, is how we could hold in the psychological sense, the chaos, suffering and anguish that people came with but not be reflecting back the chaos.
I think, the impulse to try and do a lot, you know, it's really good to notice and to be thoughtful, gentle and calm and not anxious about trying to get too much done.
There's lots of things that really push us to do that, there’s the medico-legal issues can really put pressure on to try and do too much, but I have a strong sense that if the engagement is real and it can work in a gentle way with people, then n medico legal issues don't arise.
That anxiety to try and meet guidelines can just be put aside so to navigate and negotiate priorities and just work through methodically is a much, much more effective way of working and really does produce good outcomes. As we’ve seen tonight, this is a real live case.
We've got a couple of minutes left an
Daniela: I’d like to sneak in one more question that we received. “Is there any way that the Aboriginal patient can be managed well without having an Aboriginal health worker in the practice?”
Mary: Yes, is the answer. I think that there's huge advantages in working alongside a non-Indigenous clinician in working alongside other Aboriginal workers, health workers or support workers, but it's entirely possible to work effectively without Aboriginal people in the consultation, without Aboriginal staff in consultation too.
I think that the general things of being, respectful, kind, having high standards of clinical practice, and checking the patient work really well. There’s as a couple of things I just want to add because it's also really important in this conversation that we acknowledge the shortcomings of generalizing. The case that were presented tonight is typical in some ways but it's not all Aboriginal people and need to avoid stereotyping work. There's also another principle that's really important, which is about choice. Aboriginal people, some will choose to go Aboriginal organizations, health services and others choose very deliberately not too. So I think that that's also a really important principle. .
Daniela. Fantastic and just on that not about choice “In mainstream, they may not have Aboriginal health workers. Is there a way to engage one for a patient if they want one or if the practice feels that they should have one?”
Mary: Through the PHN the ITC workers, I don't absolutely know for sure that every ITC team has Aboriginal workers, but that's certainly the intention. So, that's one way to have Aboriginal workers in the healthcare team. Also, the scope of practice of Aboriginal health workers has been expanded and Aboriginal health workers work in some community health sciences. I think, can be employed in private channel practices, and hopefully we’ll see it increasing, particularly in practices where there are large numbers of Aboriginal patients.
Daniela: Thank you. We have now reached our time. Thank you presenters and participants.