The purpose of the GBACC project is to introduce and evaluate a new strategy for integrated community-based, intensive chronic condition management of people with poorly controlled diabetes by Indigenous Health Workers (IHWs).
The primary outcome measure is a reduction in HbA1c as a result of better care processes e.g. General Practice Management Plans (GPMP) and Team Care Arrangements (TCA). Secondary outcomes relate to improved quality of life and other clinical markers such as blood pressure, lipids and renal function.
A key to the success of the Indigenous Health Workers in their role as care coordinators is their connection with the local community. Their employment has had positive benefits for client engagement and positive change in behaviour has been observed in some clients.
The project has completed Phase 1 of the RCT of intensive case management by IHWs which ran for 18 months from March 2012 to September 2013.
Participants in the study are Indigenous adults aged between 18 and 65 years of age who are resident in one of the 12 communities participating in the study. Participants had diabetes for greater than one year with an HbA1c of greater than 8.5mmol/L and at least one other chronic condition i.e. hypertension, chronic obstructive pulmonary disease, coronary heart disease and chronic renal disease (stages 1-3)
The 12 communities participating in the study are shown in the map. There are 6 services in the Torres and NPA Hospital and Health Service (HHS) region (Badu Island, Bamaga, Injinoo, New Mapoon, Seisia and Umagico), 3 services in the Cape York HHS region where services are delivered by Queensland Health, Apunipima Cape York Health Council and RFDS (Kowanyama, Mapoon, Napranum) and 3 communities in the Cairns and Hinterland HHS region where the service providers are all Aboriginal community controlled health services. They are Mareeba (Mulungu Medical Service) Mossman Gorge (Apunipima Cape York Health Council, ACYHC) and Yarrabah (Gurriny Yealamucka Health Service)
The intervention is intensive case management by IHWs recruited and trained specifically for the project with support from an Indigenous Clinical Support Team (ICST) based in Cairns who provide ongoing training and assistance. Usual care was delivered in the wait list communities during Phase 1 of the project and which did not include input from the ICST. The intervention communities are Badu Island, Injinoo, Umagico, Mapoon, Kowanyama and Mossman Gorge and the wait list communities are Yarrabah, Mareeba, Napranum, Bamaga, New Mapoon and Seisia.
These findings are based on preliminary data from Phase 1 end point data collection.
The primary outcome measure was a 1% reduction in HbA1c over 18 months. Preliminary data showed there was a reduction in HbA1c in both the intervention (.841) and control sites (.310). The results are clinically significant, but did not reach statistical significance. This is due to the small numbers and some missing clinical data. Low-Density Lipoprotein (LDL) was the only other clinical measure where the positive change was seen to be close to statistical significance. While many of the clinical measures are moving in the right direction, some measures are not improving e.g. Estimated Glomerular Filtration Rate (eGFR) in both intervention and control sites and blood pressure in control sites.
Process measures including GPMP and TCA were reviewed. Intervention sites were 26% more likely to have implemented a GPMP at T3, however this did not reach statistical significance.
An analysis of HbA1c levels by the presence or absence of a GPMP was undertaken to assess if having a GPMP makes any difference to glycaemic control. A total of 204 patients had HbA1c measured at both baseline and endpoint with a median of 0.3 (SD 2.5) and IQR -3.4 and 0.9 (ranging from -9.4 to 6.4). 211 patients had records of GPMP. There was no correlation between having a GPMP and HbA1c change. This may be due to the fact that many GPMPs were done quite close in time to the T3 data collection point, so the chance for the GPMP to have any impact would be small. Further follow up may show a stronger relationship between having a GPMP and improved clinical indicators.
A key to the success of the IHWs in their role as care coordinators is their connection with the local community.
The employment of Indigenous Health Workers appears to have had positive benefits for client engagement and positive change in behaviour has been observed in some clients. However IHWs were often frustrated by the lack of response from some participants and problems with client follow up.
The training provided by the project has improved the GBACC workers confidence in their role as chronic care coordinator and increased their level of job satisfaction. Areas for improvement in training include basic computer skills as many of the IHWs had difficulties with reporting due to a lack of knowledge of word processing and limited computer skills. The other key area for training in future is in venipuncture.
The key infrastructure issue for all GBACC IHWs was access to transport. There is an expectation within the project that the GBACC IHW will routinely conduct home visits, but this has not been possible because of lack of access to vehicles. Other infrastructure issues commonly reported were phones down, access to computers and the internet, lack of clinical equipment and limited office accommodation or clinic space thus affecting privacy provided to clients.
There was positive support for the model of service delivery from the IHWs, clients and many stakeholders. IHWs feel confident doing care coordination, patient education and routine care when provided the training and support to undertake these tasks. In some cases new practices have been established to address issues identified e.g. handover of clients, regular meetings between service providers, but there are a number of areas where work is required to achieve better clinical outcomes.
It was suggested the model and the role of the GBACC IHW needed to be communicated better to health service staff as their fellow team members need to understand their capability and respect their cultural connections in making the model work. The community trust the IHW particularly in the role of educator, care provider and facilitators of access to the health system.
It was expected that increasing the clinical skills of the IHWs, would empower them sufficiently to bring about change in their clients. This alone is not sufficient and it is clear that the system around the IHW needs to be functional for more effective empowerment by the IHW. Action is required to change the workplace culture to develop a more effective team approach at the service and clinic level. There is the opportunity to work with local sites during orientation and site visits to address this issue. Having a supportive work environment was identified by the group as a key attribute of an effective service model
Service providers would benefit from increased awareness about the project and the role of the GBACC IHW needs to be clarified. New staff did not have a good understanding of the role of the GBACC IHW. Some service providers expected the GBACC IHW to provide all clinical care and did not recognise that all members of the multidisciplinary team contribute to care, or that the role of the GBACC IHW is to facilitate access to services as well as deliver services within their scope of practice.
Strategies suggested to address this issue include incorporating information about the project into the orientation program for new staff and implementing a system of regular contact with the service supervisor.
There has been positive feedback from the GBACC IHWs about the training program delivered by the ICST. Feedback from service providers suggests there needs to be a better understanding by supervisors and members of the multidisciplinary team about the training provided to GBACC IHW. There also needs to be a stronger link between training provided and supervised practice of these skills within the workplace to ensure the GBACC IHW achieves competency.
To effectively manage care coordination all information about a client needs to be located in a central record. The best practice approach to managing client records is an electronic patient information system. In the Torres Strait and Cape York communities there are a number of different record management systems being used which has made it difficult to access all the information needed to manage care and to communicate to colleagues about the progress of care. Therefore a single point electronic health record for all teams to access is critical to the success of the service delivery model and improved patient outcomes. While this issue is bigger than the research project can solve, data from the project evaluation activities provides evidence of the risk associated with the current practice.