Abstract
Who is it for? Aboriginal Australians have higher rates of chronic health conditions, unplanned readmissions, and avoidable admissions. More than two-thirds (70%) of the health gap for Indigenous Australians are attributed to chronic health conditions. Challenges in access to culturally appropriate healthcare are commonly experienced. The 48 Hour Follow Up program targets Aboriginal people aged 16 years and above with selected chronic conditions.
Who did you involve and engage with? Local implementation was co-designed through a collaborative process involving the district’s Aboriginal Health Unit, local Aboriginal community organisations and clinicians.
What did you do? Please explain the initiative or intervention.
The program is a telephonic intervention with the immediate goal to address service gaps. In the long-term, it aims to reduce utilisation rates for avoidable hospital/emergency department re/admissions.
It is delivered by a multidisciplinary clinical team. The team calls each eligible client 48 hours post hospital discharge using a standardised script. The call provides a wellbeing check and assessment of the client’s health literacy on their chronic condition, self-management, medications and appointments.
The program was reviewed internally through descriptive before and after analysis of service data. Focus groups were conducted with program staff.
What results did you get? What impact did you have? Reductions were seen in the frequency of avoidable admissions in the first month post-program and 6 months following the intervention.
Emergency Department (ED) presentations showed reductions in the first month, at 3 months and 6 months following the intervention. Reductions are also seen in the frequency of ED presentations at the first month, 3 months and 6 months following the intervention. No reductions were found in 28-day readmissions.
Clinicians reported their work on the program was fulfilling due to connections made with clients and the immediate benefits witnessed, such as addressing medication issues. It was identified that program implementation extended beyond the initial post-discharge phone call, with staff following up information on behalf of clients and maintaining contact via telephone until issues were resolved.
What is the learning for the international audience? Telephonic post-discharge programs can deliver positive outcomes for First-Nations clients. Elements of program delivery included: establishing connections with clients; providing care navigation; improving health literacy; following up missing or unclear information with the hospital wards; maintaining contact with the client until issues were resolved.
What are the next steps? These findings will be used to redesign the program’s model of care. This will involve a co-design process to ensure the program is more responsive to the needs of Aboriginal people living with chronic conditions.