MAKING A DIFFERENCE CHRONIC CONDITIONS PREVENTION AND MANAGEMENT FOR ABORIGINAL CLIENTS IN THE NORTHERN TERRITORY

Transcription

1 MAKING A DIFFERENCE CHRONIC CONDITIONS PREVENTION AND MANAGEMENT FOR ABORIGINAL CLIENTS IN THE NORTHERN TERRITORY Dr Christine Connors and Liz Kasteel Chronic Conditions Strategy Unit NT Department of Health Department of Health is a Smoke Free Workplace

2 Outline NT Burden of Disease NT Chronic Conditions Prevention and Management Strategy (NT CCPMS) The current approach What do the NT data show? 2

3 Burden of Disease Zhao, Y et al. Burden of disease and injury in the Northern Territory, , Department of Health, Darwin, 29 3

4 Major health risk factors and contribution to the total burden of disease in NT Risk factor Low socio-economic status High body mass Physical inactivity Tobacco Alcohol High blood cholesterol Low fruit and veg intake Attributable proportion 26.8% 11.1% 11.% 8.1% 4.5% 4.2% 3.3% 4

5 NT CCPMS - PRIORITIES & KAAs Priority conditions Cardiovascular disease Rheumatic heart disease Type-2 diabetes Chronic airways disease Chronic kidney disease Chronic mental illness Cancers Key Action Areas SDoH Primary prevention Secondary prevention Self management support Care for people with CC Workforce IT, communication, disease mgt systems Quality improvement 5

6 NT CCPMS - Framework Individual, carer and family centred care Community capacity System supports to enable interventions Interventions across the care continuum to achieve population health outcomes 6

7 Chronic Care Model Supportive Health Systems As a focus in Departmental Corporate Plan thus a priority in all programs Increased opportunities to training/education Increased dedicated position: Care Coordinator, CQI Coordinators Self-management Support Recent - Development of NT Self- management Framework Target specific work unit to implement SM Develop NT specific SM tool for Aboriginal clients (current work) SM training for Health Professionals 7

8 Chronic Care Model Clinical Info System Improved recall system (current work), disease registers (current work for diabetes in pregnancy) Standard clinical guidelines (CARPA, 6 th edition ) Strengthen, supportive IT system: my e-health record Delivery System Design Strengthen model for Medical Specialist Outreach program SONT Care coordination model for ESKD Systematic investment in continuous quality improvement (CQI) 8

9 CQI in NT Aboriginal PHC Establishment of NT Aboriginal PHC CQI support 2 regional coordinators based with AMSANT (Kerry and Louise) 16 CQI positions across NT Using range of tools including one21seventy Know your CQI facilitator and read your HC reports NTAHKPI, one21seventy audits, CQI action plan Accreditation of services NTAHKPI s 6 monthly reporting automatic extract from PCIS and Communicare NT report will be released early 212 Active engagement of clinicians and managers 9

10 How are we doing so far? Life expectancy at birth Leading causes of deaths Infant mortality Total deaths CQI audit Recommended services for diabetes Blood pressure control HbA1c 1

11 Life expectancy at birth, by Indigenous status, Northern Territory and Australia, 1967 to 26 MALES FEMALES Life expectancy at birth (years) Indigenous male Non-Indigenous male Australian male Life expectancy at birth (years) Indigenous female Non-Indigenous female Australian female Year Year Tay E, Li SQ, Guthridge S, DRAFT Mortality in the Northern Territory, Department of Health, Darwin 11

12 Leading causes of death, NT Aboriginal and non- Aboriginal, Department of Health, 211. Mortality in the Northern Territory,

13 Mortality from chronic disease: NT Aboriginal people (trend) Mortality rate per 1 Mortality rate per 1 Mortality rate per 1 Mortality rate per Ischaemic heart disease NT Indigenous Total Australian Chronic obstructive pulmonary disease Diabetes mellitus Cerebrovascular disease Thomas DP et al, Long term trends in Indigenous deaths from chronic diseases in the NT: a foot on the Brake, a foot on the accelerator. MJA 26; 185(3):

14 Infant mortality, NT Most common cause of death -4 yrs Death per 1, population 3 25 NT Indigenous Perinatal Infectious Injury All Other Congenital Endocrine Respiratory Death per 1, population 3 25 NT non-indigenous Perinatal Infectious Injury Other Congenital Endocrine Respiratory Year Year Tay E, Li SQ, Guthridge S, Mortality in the Northern Territory, Department of Health, Darwin 14

15 CQI - audit DM audits NT Aboriginal PHC services 15

16 CQI - audit 16

17 Number Number of New Dialysis Patients in NT, Year Source:?? 17

18 Death rates Closing the Gap Projection to 231 Rate per Actual Indigenous Projected Indigenous rate Indigenous variability bands Actual non-indigenous Projected non-indigenous rate Indigenous trend Based on the trend line from 1998 to 21, the Northern Territory is the only jurisdiction which is on track to meet its 231 target!! COAG Reform Council 212, Indigenous reform 21 11: Comparing performance across Australia, Chapter 2: Life expectancy. COAG Reform Council, Sydney 18

19 NT Department of Health 1. Northern Territory Chronic Conditions Prevention and Management Strategy, Annual Report 21, Chronic Conditions Prevention and Management Strategy, Annual Report 211, Chronic Conditions Prevention and Management Strategy, TO BE RELEASED 19