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“You Can’t Work with My People If You Don’t Know How to”: Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease

Author

Listed:
  • Ilse Blignault

    (Translational Health Research Institute, Western Sydney University, Penrith, NSW 2751, Australia)

  • Liz Norsa

    (Translational Health Research Institute, Western Sydney University, Penrith, NSW 2751, Australia)

  • Raylene Blackburn

    (South Western Sydney Local Health District, Liverpool, NSW 1871, Australia)

  • George Bloomfield

    (South Western Sydney Local Health District, Liverpool, NSW 1871, Australia)

  • Karen Beetson

    (South Western Sydney Local Health District, Liverpool, NSW 1871, Australia)

  • Bin Jalaludin

    (South Western Sydney Local Health District, Liverpool, NSW 1871, Australia
    Ingham Institute for Applied Medical Research, UNSW Sydney, Liverpool, NSW 2170, Australia)

  • Nathan Jones

    (South Western Sydney Local Health District, Liverpool, NSW 1871, Australia)

Abstract

Indigenous Australians experience significantly poorer health compared to other Australians, with chronic disease contributing to two-thirds of the health gap. We report on an evaluation of an innovative model that leverages mainstream and Aboriginal health resources to enable safe, supported transfer of care for Aboriginal adults with chronic conditions leaving hospital. The multisite evaluation was Aboriginal-led and underpinned by the principles of self-determination and equity and Indigenous research protocols. The qualitative study documented processes and captured service user and provider experiences. We found benefits for patients and their families, the hospital and the health system. The new model enhanced the patient journey and trust in the health service and was a source of staff satisfaction. Challenges included staff availability, patient identification and complexity and the broader issue of cultural safety. Critical success factors included strong governance with joint cultural and clinical leadership and enduring relationships and partnerships at the service delivery, organisation and system levels. A holistic model of care, bringing together cultural and clinical expertise and partnering with Indigenous community organisations, can enhance care coordination and safety across the hospital–community interface. It is important to consider context as well as specific program elements in design, implementation and evaluation.

Suggested Citation

  • Ilse Blignault & Liz Norsa & Raylene Blackburn & George Bloomfield & Karen Beetson & Bin Jalaludin & Nathan Jones, 2021. "“You Can’t Work with My People If You Don’t Know How to”: Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease," IJERPH, MDPI, vol. 18(14), pages 1-17, July.
  • Handle: RePEc:gam:jijerp:v:18:y:2021:i:14:p:7233-:d:589523
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    References listed on IDEAS

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    1. Wanda Phillips-Beck & Rachel Eni & Josée G. Lavoie & Kathi Avery Kinew & Grace Kyoon Achan & Alan Katz, 2020. "Confronting Racism within the Canadian Healthcare System: Systemic Exclusion of First Nations from Quality and Consistent Care," IJERPH, MDPI, vol. 17(22), pages 1-20, November.
    2. Julieann Coombes & Sarah Fraser & Kate Hunter & Rebecca Ivers & Andrew Holland & Julian Grant & Tamara Mackean, 2021. "“They Are Worth Their Weight in Gold”: Families and Clinicians’ Perspectives on the Role of First Nations Health Workers in Paediatric Burn Care in Australia," IJERPH, MDPI, vol. 18(5), pages 1-13, February.
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    Cited by:

    1. Kalinda Griffiths & Abbey Diaz & Lisa J. Whop & Joan Cunningham, 2021. "The Health and Wellbeing of Indigenous and Tribal Peoples around the Globe: Ensuring and Promoting Best Practice in Research," IJERPH, MDPI, vol. 19(1), pages 1-9, December.

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