Monitoring and Evaluation of the Indigenous Chronic Disease Package: Final Report

Australian Government Department of Health

Monitoring and Evaluation of the Indigenous Chronic Disease Package

Final Report Volume 1: Evaluation of the overall package and its individual measuresJune 2014

National Monitoring and Evaluation of the Indigenous Chronic Disease Package Volume 1: Final Report (2013)

Online ISBN: 978-1-76007-165-3

Publications approval number: 11037

Copyright Statement:

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This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Communication Branch, Department of Health, GPO Box 9848, Canberra ACT 2601, or via e-mail to copyright@health.gov.au.

This report has been independently prepared for the Australian Government Department of Health by KPMG Australia, and does not necessarily represent the views of the Australian Government.

The evaluation of the Indigenous Chronic Disease Package was commissioned by the Department of Health. This evaluation report has been prepared by KPMG Australia.

The report’s lead authors were the National Health and Human Services Practice, KPMG.

The other major contributors to the report were: Dr Brita Pekarsky of the Baker IDI Heart & Diabetes Institute; and Winangali.

KPMG wishes to acknowledge the following stakeholders for their contribution to the evaluation through giving their time and sharing their experiences: the Department of Health, state and territory health departments, the National Aboriginal Community Controlled Health Organisation and its Affiliates, peak bodies, Aboriginal Health Services, Divisions of General Practice/Medicare Locals, the Indigenous Health Partnership Forums, ICDP workers and their fund holder representatives, general practice staff and community members.

Citation

National Monitoring and Evaluation of the Indigenous Chronic Disease Package

Final Report

June 2014

KPMG 2014, National Monitoring and Evaluation of the Indigenous Chronic Disease Package: Final Report (2014), Australian Government Department of Health, Canberra.

KPMG is an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in Australia. KPMG and the KPMG logo are registered trademarks of KPMG International. Liability limited by a scheme approved under Professional Standards Legislation.

Table of Contents

Table of Contents2

List of tables4

List of figures9

Glossary12

Indigenous Chronic Disease Package measures14

Key Terms15

Reading this report18

Executive Summary20

Overview of the ICDP20

Context20

Monitoring and Evaluation of the ICDP22

Findings: progress with implementation24

Findings: impacts on the health service system27

Findings: impacts for Aboriginal and Torres Strait Islander people29

Future focus33

1Whole of Indigenous Chronic Disease Package36

1.1Evaluation of the Package36

1.2Contextual influences78

1.3Case study 1: Embedding health promotion in primary health care organisations93

1.4Case study 2: Building individual and community capacity113

1.5Case study 3: Indigenous Chronic Disease Package workforce126

1.6Future focus148

1.7Implementation of future strategies148

1.8Strengthening preventive measures149

1.9Strengthening chronic disease management measures152

1.10Workforce development155

1.11Monitoring and support156

2The Indigenous Chronic Disease Package as a mechanism to tackle chronic disease risk factors159

2.1Regional Tackling Smoking Healthy Lifestyle Teams and other national level support for smoking cessation (A1 and A2 measures)161

2.2Local Community Campaigns (A3 measure)208

3Indigenous Chronic Disease Package as a mechanism to improve chronic disease management and follow up care234

3.1Subsidising PBS medicine Co-payments (B1 measure)238

3.2Increasing utilisation of Pharmaceutical Benefits Scheme and Medicare Benefits Schedule (B2 measure)299

3.3Supporting primary care providers to coordinate chronic disease management through the Practice Incentives Program Indigenous Health Incentive (B3a measure)340

3.4Supporting primary care providers to coordinate chronic disease management through care coordination (B3b measure)375

3.5Improving Indigenous participation in health care through chronic disease self management (B4 measure)407

3.6Increasing access to specialists, allied health and multidisciplinary care through outreach (B5 measure)430

4Intended contribution of the ICDP to the workforce and the health system461

4.1Enhancing the capacity of the AHS sector (AHS workforce, infrastructure and professional development components of C1 and C2 measures)464

4.2Improving community access to primary health care (ATSIOW component of the C1, C2 and C3 measures)516

4.3Improving the accessibility and responsiveness of mainstream primary health care (IHPO component of C3 measure)567

4.4Attracting more people to work in Aboriginal and Torres Strait Islander health (C4 measure)605

4.5Clinical Practice and Decision Support Guidelines (C5 measure)620

List of tables

Table 1: Changes made to the ICDP and their implications for different stakeholder groups.40

Table 2: Estimated reach of the ICDP into different cohorts of the Aboriginal and Torres Strait Islander population.43

Table 3: Barriers addressed by the ICDP and assessment of impact of the ICDP measures.48

Table 4: State and territory Closing the Gap (NPA) programs that directly relate to ICDP preventive health measures (the ‘A measures’).67

Table 5: State and territory Closing the Gap (NPA) programs that directly relate to ICDP chronic disease management measures (the ‘B measures’).68

Table 6: State and territory Closing the Gap (NPA) programs that directly relate to ICDP workforce and resource support measures (the ‘C measures’).69

Table 7: Total funding commitment by all jurisdictions to the Closing the Gap NPA over 2009 to 2013 in $ millions.70

Table 8: Imputed estimate of the share of CtG funding commitment in each state or Territory that is contributed by the Commonwealth.71

Table 9: ICDP expenditure as a percentage of total expenditure by the government jurisdiction on Aboriginal and Torres Strait Islander health 2010-11.72

Table 10 Contextual factors influencing ICDP measures A measures.90

Table 11 Contextual factors influencing ICDP measures --B measures.91

Table 12 Contextual factors influencing ICDP measures -- C measures.92

Table 13: Summary of Aboriginal and Torres Strait Islander health workforce type by sector.127

Table 14: Summary of ICDP impact on the Aboriginal and Torres Strait Islander Health workforce. 129

Table 15: ICDP workforce role (FTE) by remoteness at 31 December 2012 and 31 March 2013 for ATSIOW and IHPO.131

Table 16: ICDP workforce role by gender proportion from evaluation survey respondents.131

Table 17: ICDP evaluation survey respondents on whether they ‘understand the role’ (n = 164).134

Table 18: ICDP workforce, FTE recruited by workforce position and time.139

Table 19: ICDP Workforce, funded positions by remoteness.140

Table 20: ICDP workforce, funded positions by organisation type.140

Table 21: Number of full-time equivalent selected health staff employed by Aboriginal and Torres Strait Islander primary health-care services, by Indigenous status, at 30 June 2009, 2010, 2011 and 2012.144

Table 22: Aboriginal and Torres Strait Islander population in 2012 by remoteness and FTE RTSHLT workers as at December 2012.166

Table 23: Aboriginal and Torres Strait Islander population in 2012 by state and territory and FTE RTSHLT workers as at December 2012. Source: former Department of Health and Ageing; Australian Bureau of Statistics.166

Table 24: RTSHLT responses to evaluation survey questions related to training.184

Table 25: RTSHLT responses to evaluation survey questions relating to brief intervention training.185

Table 26: TAW responses (n = 22) to the survey question ‘Approximately how many times have you provided tobacco brief interventions to Aboriginal and Torres Strait Islander people?’185

Table 27: RTC responses (n = 13) to the survey question ‘Approximately how many times have you provided tobacco brief interventions to Aboriginal and Torres Strait Islander people?’186

Table 28: Comparison of dispensing of CtG, S100 RAAHS and full PBS co-payment smoking cessation medicines supplied per 100 smokers, 2010 to 2012.194

Table 29: Number of LCC grant recipients and LCCs.211

Table 30: Overview of responses (n = 69) to the question 'Have you accessed the Live Longer! website or used the materials provided on the website?’215

Table 31: Concepts and terms specific to the PBS Co-payment measure.238

Table 32: Number of hotline and email enquiries for 201011, 201112 and 201213.244

Table 33: EverCtG patients to have received at least one PBS script and proportions receiving CtG or non-CTG scripts, by six month period, December 2010 to December 2012, Australia.255

Table 34: CtG scripts, patients who received a CtG script, CtG scripts per patient and proportion of population, by age, Australia, six months ending December 2012.256

Table 35: CtG scripts, patients who received a CtG script, CtG scripts per patient and proportion of population, by remoteness, Australia, six months ending December 2012.256

Table 36: Distribution of CtG scripts prescribed by GPs and GP workforce by provider type and Remoteness, 2012.260

Table 37: Number of prescribers prescribing CtG scripts and CtG scripts per prescriber, by prescriber type and six month period, Australia, July 2010 to December 2012.262

Table 38: Numbers and proportions of GPs prescribing CtG scripts by prescriber type and six month period, Australia, June 2010 to December 2012.263

Table 39: Financial relief for patients dispensed a CtG script during 2012, by concessional status of patient, Australia270

Table 40: Financial relief in total and per patient, by patient concessional status for the six months ending December 2012, Australia.271

Table 41: Number of PBS scripts dispensed to EverCtG patients by six month period, Australia, June 2007 to December 2012.274

Table 42: Number of EverCtG patients dispensed at least one PBS script, by six month period, Australia, June 2007 to December 2012.275

Table 43: Summary of changes in annual trends from pre-ICDP to post-ICDP period, by EverCtG status, age group and indicator.276

Table 44: Actual and projected PBS scripts dispensed to EverCtG patients, by age, Australia, July 2010 to December 2012.278

Table 45: Actual and projected PBS scripts dispensed, by EverCtG status and remoteness, Australia, July 2010 to December 2012.279

Table 46: Actual and projected PBS scripts dispensed, by EverCtG status and age, Australia, January to December 2012.280

Table 47: Actual and projected PBS scripts dispensed, by EverCtG status and remoteness, Australia, January to December 2012.281

Table 48: Numbers of under co-pay CtG scripts dispensed, by six month period, Australia, July 2010 to December 2012.283

Table 49: Estimated range of ICDP impact on use of medicines by EverCtG patients, by age group, Australia, 2012.285

Table 50: Comparison of projected and actual use of PBS medicines by NeverCtG patients, by age group, Australia, 2012.286

Table 51: Responses to question on medicine adherence from pharmacists, AHSs, and Medicare Locals (MLs), collected in 201112 and 201213 site visits.288

Table 52: Number and proportion of EverIHI patients receiving a MBS item 900 or 903 (medication management review), six monthly, 2007 to 2012.290

Table 53: PBS scripts dispensed to EverCtG patients compared with projections, selected ATC1 classes and age groups, Australia, 2012.291

Table 54: MBS expenditure for health assessments for Aboriginal and Torres Strait Islander people, PN/AHW follow up and allied health services for Aboriginal and Torres Strait Islander people.303

Table 55: Allied health services for Aboriginal and Torres Strait Islander patients for November quarter 2010 and November quarter 2012 at the national level.312

Table 56: Allied health providers for Aboriginal and Torres Strait Islander patients for November quarter 2010 and November quarter 2012 at the national level.315

Table 57: Health assessments for Aboriginal and Torres Strait Islander people and the percentage increase on the previous 12 months of health assessments for EverIHI and NeverIHI patients aged 15 years and over, 2008 to 2012.319

Table 58: Allied health services for EverIHI and NeverIHI patients aged 15 years and over, from 2009 to 2012.319

Table 59: Number of unique EverIHI patients receiving at least one MBS service in a six month period between 2007 and 2012.320

Table 60: MBS Services by category and year for EverIHI patients.322

Table 61: GPMP, TCA and reviews for EverIHI patients by year and percentage growth on previous year in brackets.324

Table 62: CtG scripts, patients receiving at least one CtG script, total PBS benefits for CtG scripts and CtG benefits, by concessional and safety net status, Australia, July 2010 to December 2012.329

Table 63: Numbers of CtG and Non CtG scripts and CtG scripts dispensed to EverCtG patients, by six month periods, Australia, December 2007 to December 2012.330

Table 64: Actual health assessments by calendar year, projected health assessments and difference to actual.332

Table 65: Trend break analysis summary table. *336

Table 66: Patient registrations by state and year with percentage growth from previous year.346

Table 67: Patient reach by state and territory and calendar year.348

Table 68: Patient reach by remoteness and calendar year.348

Table 69: Primary health care service registrations, patient registrations and average patient registrations per primary health care service by primary health care service type from commencement of the PIP Indigenous Health Incentive to November 2012.350

Table 70: Patients receiving services through Care Coordination Supplementary Services, December quarters of 2011 and 2012.385

Table 71: Use of Supplementary Service Funds by Care Coordinator Survey Respondents (n = 62).388

Table 72 Specialty and other health professional services delivered by the MSOAPICD 2012.447

Table 73 Types of medical specialties provided across Australia through USOAP at July 2012.450

Table 74: Capital works projects funded/supported by the ICDP, by jurisdiction, 2009-10 to April 2013.470

Table 75: Number of C2 Practice Managers and other health workforce FTE allocated and actual recruitment and proportion of allocated positions filled (%), July 2009- March 2013.472

Table 76: C2 Practice Managers and other health workforce FTE recruited by jurisdiction, as at 30 June 2010, 30 June 2011, 30 June 2012 and 31 March 2013.472

Table 77: OATSIH Services Report data summary, only AHSs that reported all three years, 2008-09 to 2010-11.484

Table 78: Office of Aboriginal and Torres Strait Islander Health (OATSIH) Services Report data summary, selected AHSs that received funding under the C2 measure, 2008-09 to 2010-11.485

Table 79: Funded and total ICDP nursing scholarships, 2010-12.493

Table 80: Number of nursing and midwifery ICDP scholarships provided by jurisdiction, 2010-12.495

Table 81 Rate of nursing and midwifery ICDP scholarship uptake by jurisdiction, 2012.496

Table 82: ATSIOW workforce allocated to June 2012 and recruited FTE as at 31 March 2013, and proportion of allocated positions (%) by sector.521

Table 83: ATSIOW workforce FTE recruited by jurisdiction, as at 30 June 2010, 30 June 2011, 30 June 2012, 30 December 2012 and 31 March 2013.521

Table 84: ATSIOW workforce FTE recruited by remoteness, as at 30 June 2010, 30 June 2011, 30 June 2012, 31 December 2012 and 31 March 2013.522

Table 85: Delivery of ATSIOW orientation packages, by jurisdiction and number of ATSIOWs recruited, 201011 to 201213.529

Table 86: Number of ATSIOWs recruited who received training support from the ICDP, 201011 to 201213.533

Table 87: Average number of episodes of assistance to individuals provided by ATSIOWs in the mainstream sector, by type of assistance.548

Table 88: ATSIOW survey responses to statement: ’The programs/services I provide are addressing the real needs of the local Aboriginal and Torres Strait Islander community’.551

Table 89: Allocated and recruited FTE for IHPO positions as at 31 March 2013.571

Table 90: IHPO workforce FTE recruited by jurisdiction, as at 30 June 2010, 30 June 2011, 30 June 2012, 31 December 2012 and 31 March 2013.571

Table 91: IHPO workforce FTE recruited by remoteness area, as at 30 June 2010, 30 June 2011, 30 June 2012, 31 December 2012 and 31 March 2013.572

Table 92: Responses to the ICDP evaluation survey.611

List of figures

Figure 1: Overview of the ICDP’s intended contribution to individual capacity through community-based health promotion and support, and clinic-based health education and support.116

Figure 2: Observed progress of the ICDP ‘healthy lifestyle’ components against the intended pathway. Source: KPMG.160

Figure 3: National Action to Reduce Indigenous Smoking Rates causal pathway. Source: KPMG.175

Figure 4: Helping Indigenous Australians Reduce their Risk of Chronic Disease causal pathway. Source: KPMG.176

Figure 5: Medicines used in nicotine dependence (tobacco cessation medicines) for EverCtG patients, S100 RAAHS and other PBS, by six monthly periods, Australia, December 2008 to December 2012.193

Figure 6: Reported reach achieved by LCCs (n = 56) by LCC style. Source: LCC program documentation and consultation with LCC management.213

Figure 7: LCC measure causal pathway. Source: KPMG.217

Figure 8: Observed progress of the ICDP ‘chronic disease management’ components against the intended access pathway. Source: KPMG.236

Figure 9: Observed progress of the ICDP ‘chronic disease management’ components against the intended care coordination pathway. Source: KPMG.236

Figure 10: Observed progress of the ICDP ‘chronic disease management’ components against the intended self management pathway. Source: KPMG.236

Figure 11: Number of CtG scripts dispensed, by six month period, Australia, December 2010 to December 2012.251

Figure 12: Index of number of patients dispensed a CtG script and average CtG scripts per patient, by six month period, Australia (July to December 2010 = 100).252

Figure 13: Numbers of CtG and non-CtG scripts, EverCtG patients by six month periods, Australia, June 2007 to December 2012.254

Figure 14: Distribution of CtG scripts dispensed by ATC1 class, by age, Australia, six months ending December 2012.258

Figure 15: Pharmacies dispensing at least one CtG script and CtG scripts per pharmacy, by six month period, Australia, December 2010 to December 2012.264

Figure 16: PBS Co-payment causal pathway. Source: KPMG.265

Figure 17: Medicare health assessments for Aboriginal and Torres Strait Islander people, August 2008 quarter to November quarter 2012.304

Figure 18: Health assessments for Aboriginal and Torres Strait Islander people, services from PNs/AHWs and allied health services for Aboriginal and Torres Strait Islander people for August 2008 quarter to November 2012 quarter.308

Figure 19: PNs/AHWs providing at least one follow up in quarter and follow ups per provider November 2008 to November 2012.310

Figure 20: Number of PN/AHW follow up services and allied health services per 100 health assessments, February quarter 2009 to November quarter 2012.316

Figure 21: GPMPs and TCAs for EverIHI patients from 2008 to 2012.323

Figure 22: Pathology services and the percentage increase on the previous twelve months of pathology services for EverIHI patients 2007 to 2012.325

Figure 23: General (M3) and Aboriginal and Torres Strait Islander-specific (M11) allied health services between 2007 and 2012 for EverIHI patients.327

Figure 24: Numbers of PBS scripts dispensed and pre- and post-ICDP trends, EverCtG patients by six month periods, Australia, June 2007 to December 2012.328

Figure 25: Number of Medicare health assessments for Aboriginal and Torres Strait Islander people by month (July 2007 to November 2012) and linear trend projection of health assessments delivered between July 2007 and December 2009.331

Figure 26: Professional attendances and health assessments for EverIHI patients by six month periods.334

Figure 27: Distribution of services by group within Category 1 Professional Attendances.338

Figure 28: PIP Indigenous Health causal pathway. Source: KPMG.351

Figure 29: GPMPs, TCA and reviews for EverIHI patients for 2007 to 2012.362

Figure 30: Proportion and number of registered patients by payment type for 2010, 2011 and 2012.363

Figure 31: Distribution of recruited FTE Care Coordinators and Aboriginal and Torres Strait Islander population by level of remoteness.379

Figure 32: Distribution of recruited FTE Care Coordinators and Aboriginal and Torres Strait Islander population by jurisdiction.380

Figure 33: CCSS program causal pathway. Source: KPMG.391

Figure 34: Number of CDSM trainees trained during the Funding Period (200913).411

Figure 35: Chronic Disease Self Management causal pathway.417

Figure 36: Increasing access to specialist care: combined USOAP and MSOAP-ICD program causal pathway. Source: KPMG.440

Figure 37: Map showing locations of MSOAP-ICD service delivery in 201112 and 201213.449

Figure 38: Map showing locations of USOAP service delivery in 201112 and 201213.451

Figure 39: Observed progress of the ICDP ‘workforce enhancement and support’ components against the intended pathway. Source: KPMG.462

Figure 40: Causal pathway for Expanding the Outreach and Service Capacity of Indigenous Health Organisations measure components: capital works and Practice Manager and additional health professional positions. Source: KPMG.476

Figure 41: Causal pathway for Workforce Support, Education and Training measure components: AHS GP registrar training posts and nursing scholarships. Source: KPMG.499

Figure 42: Causal pathway for the C1 measure (ATSIOW component). Source: KPMG.537

Figure 43: Causal pathway diagram for C2 measure (ATSIOW component). Source: KPMG.537

Figure 44: Causal pathway for C3 measure (ATSIOW component). Source: KPMG.538

Figure 45: Causal pathway for the Improving Indigenous Access to Mainstream Primary Care (C3 measure): IHPO component. Source: KPMG.581

Figure 46: Attracting More People to Work in Indigenous Health causal pathway. Source: KPMG.612

Figure 47: Clinical Practice and Decision Support Resources causal pathway. Source: KPMG.625

Glossary

Acryomn

Descriptions

ABS

Australian Bureau of Statistics

ACN

Australian College of Nursing

AGPN

Australian General Practice Network

AGPT

Australian General Practice Training

AHLO

Aboriginal Health Liaison Officer

AHS

Aboriginal health service

AHW

Aboriginal Health Worker

AIHW

Australian Institute of Health and Welfare

AMS

Aboriginal Medical Service

ATC

Anatomical Therapeutic Chemical

ATSIOW

Aboriginal and Torres Strait Islander Outreach Worker

CCSS

Care Coordination and Supplementary Services (B3b measure)

CDSM

Chronic Disease Self Management

CHAP

Community Health Action Pack

CEO

Chief Executive Officer

CRG

Campaign Reference Group

CtG

Closing the Gap (relates to scripts dispensed through the PBS Copayment measure of the ICDP)

DAA

Dose Administration Aid (Webster pack)

DHS

Australian Government Department of Human Services

DoGP

Division of General Practice

EQHS

Establishing Quality Health Standards

FTE

Full time equivalent

GP

General Practitioner

GPET

General Practice, Education and Training Limited

GPMP

General Practice Management Plan

H4L

Healthy for Life

HLW

Healthy Lifestyle Worker

ICDP

Indigenous Chronic Disease Package

IHPF

Indigenous Health Partnership Forum

IHPO

Indigenous Health Project Officer

LCC

Local Community Campaign

MBS

Medicare Benefits Schedule

MOICDP

Medical Outreach - Indigenous Chronic Disease Program

MSOAP

Medical Specialist Outreach Assistance Program

MSOAP-ICD

Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease

NACCHO

National Aboriginal Community Controlled Health Organisation

NAHSSS

Nursing and Allied Health Scholarship and Support Scheme

NPA

National Partnership Agreement

OAHTSIH

Office of Aboriginal and Torres Strait Islander Health

PBS

Pharmaceutical Benefits Scheme

PIP

Practice Incentives Program

PN

Practice nurse

QUMAX

Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander people

RA

Remoteness area

RACGP

Royal Australian College of General Practice

RTC

Regional Tobacco Coordinator

RN

Registered Nurses

RTP

Regional Training Provider

SSE

Sentinel Sites Evaluation

S100 RAAHS

Section 100 Remote Area Aboriginal Health Service.

Supply of pharmaceutical benefits to remote area Indigenous health services under section 100 of the National Health Act 1953

SBO

The (previous) State Based Organisations representing Divisions of General Practice

TAW

Tobacco Action Worker

TCA

Team Care Arrangement

TRG

Technical Reference Group

USOAP

Urban Specialist Outreach Assistance Program

VET

Vocational Education and Training

WHO

World Health Organization

Indigenous Chronic Disease Package measures

Measure

Descriptions

A1

National Action to Reduce Indigenous Smoking Rates

A2

Helping Indigenous Australians Reduce Their Risk of Chronic Disease

A3

Local Indigenous Community Campaigns to Promote Better Health

B1

Subsidising PBS Medicine Co-payments

B2

Higher Utilisation Costs for MBS and PBS

B3a

Supporting Primary Care Providers to Coordinate Chronic Disease Management

B3b

Supporting Primary Care Providers to Coordinate Chronic Disease Management

B4

Improving Indigenous Participation in Health Care through Chronic Disease Self Management

B5a

Increasing Access to Specialist Care

B5b

Increasing Access to Specialist and Multidisciplinary Team Care

C1

Workforce Support, Education and Training

C2

Expanding the Outreach and Service Capacity of Indigenous Health Organisations

C3

Engaging Divisions of General Practice to Improve Indigenous Access to Mainstream Primary Care

C4

Attracting More People to Work in Indigenous Health

C5

Clinical Practice and Decision Support Guidelines

Key Terms

Key terms

Descriptions

ATC1

Anatomical Main Group level of the Anatomical Therapeutic Chemical (ATC) classification. Medicines which fall within the anatomical main group of ATC and consist of one letter.

ATC2

Therapeutic Subgroup level of the ATC classification. Medicines which fall within the anatomical main group of ATC and consist of two digits.

Aboriginal health sector

In this document, this includes Aboriginal health services and NACCHO state/territory affiliates.

Aboriginal health service

In this document, collectively Aboriginal Community Controlled Health Organisations, state/territory managed Aboriginal health services and other non-community controlled Aboriginal health services designed primarily to meet the needs of Aboriginal and Torres Strait Islander people.

Adult health assessments

Claims made for the Medicare health assessment for Aboriginal and Torres Strait Islander people (MBS items 704, 706, 710 and, after 1 May 2010, 715) by people aged ≥15 years.

Baseline Report

the Baseline Report of the Indigenous Chronic Disease Package (ICDP) National Monitoring and Evaluation Project

Clinician

A health professional such as a general practitioner (GP), nurse or Aboriginal Health Worker.

Division of General Practice

May also refer to the Medicare Locals. During the evaluation period, changes occurred to fund holder arrangements; namely the allocation of funding to Medicare Locals, rather than via Divisions of General Practice (DoGPs). This occurred as a result of the national health reforms that led to establishment of Medicare Locals and commenced from 1 January 2013. It is recognised that the rates to Medicare Locals varied during the evaluation.

CtG scripts

Used by service providers and community members to refer to scripts which have been CtG annotated to provide the patient with access to the PBS co-payment subsidy (B1) measure.

Early outcomes/ results

The outcomes expected in years two to four of the Indigenous Chronic Disease Package (ICDP) as specified in the Evaluation Framework.

EverCtG

All Aboriginal and Torres Strait Islander people who have ever been dispensed one CtG script at the time data was extracted.

EverIHI

All Aboriginal and Torres Strait Islander people who have ever been registered for the PIP Indigenous Health Incentive at the time data was extracted. This includes people who registered once but may not have re-registered.

First Monitoring Report

First Monitoring Report of the Indigenous Chronic Disease Package (ICDP) National Monitoring and Evaluation Project

General Practice

Private General Practices.

General practitioner

Medical doctors based in both private General Practice and Aboriginal health services

General Practice Sector

Includes private General Practice, Division of General Practice and State-Based Organisations.

Indigenous

Is used when referring to the Indigenous Chronic Disease Package measures as per the usage in Commonwealth Government documents. The term should be read to be synonymous with the phrase 'Aboriginal and Torres Strait Islander people' as used elsewhere in the report.

Longer term results

The outcomes expected in years five to ten of the ICDP as specified in the Evaluation Framework.

Mainstream general practices

In this document this refers to private or public General Practice which primarily provides primary health care services to non-Aboriginal and Torres Strait Islander people.

Measure manager

A Department of Health program manager for a specific ICDP measure.

Medicare quarter

Medicare quarter in this report refers to data periods, the four Medicare quarters are:

Jun-Aug

Sept-Nov

Dec-Feb

Mar-May

Medium Term outcomes / results

The outcomes expected in years four to five of the Indigenous Chronic Disease Package as specified in the Evaluation Framework.

National Framework

The National Monitoring and Evaluation Framework that was developed to guide the ongoing monitoring and evaluation of the Indigenous Chronic Disease Package measures.

NeverCtG

Aboriginal and Torres Strait Islander people who have never been dispensed a CtG script.

NeverIHI

Aboriginal and Torres Strait Islander people that have never registered for the PIP Indigenous Health Incentive but who have received Aboriginal and Torres Strait Islander-specific MBS Services.

Preventive health workforce

Refers collectively to the Regional Tackling Smoking and Healthy Lifestyle teams (RTSHLTs) and the Local Community Campaign (LCC) teams as funded under the ICDP.

Regional Tackling Smoking and Healthy Lifestyle teams

Refers collectively to the following ICDP-funded workers: Regional Tobacco Coordinator, Tobacco Action Worker and Healthy Lifestyle Worker.

Second Monitoring Report

Second Monitoring Report of the ICDP National Monitoring and Evaluation Project

Specialists and other prescribers

When referring to prescribing of CtG scripts, this term includes specialists and other prescribers who are neither GPs nor nurse practitioners.

Reading this report

This report has two volumes:

Volume 1 – this report, which is the Final Report of the evaluation.

Volume 2 – ICDP Impact on Patient Journey and Service Availability Report.

This report, Volume 1, is comprised of the following parts:

Executive summary. The executive summary presents the overall findings of the evaluation along with relevant background information.

Evaluation at the whole of Indigenous Chronic Disease Package (ICDP) level – chapters 1 to 6. This part includes chapters on whole of ICDP findings, discussion of contextual influences, case study analysis relating to health promotion, individual capacity and workforce, and suggested future focus areas for the Package.

Evaluation at the measure level – chapters 7 to 20. This part of the report presents an evaluation of the ICDP measures. The measures are grouped under three priority areas based on letter number codes: tackling chronic disease risk factors (A measures); improving chronic disease management and follow up care (B measures); and; workforce expansion and support (C measures). In reality, the aims and impacts of individual measures align slightly differently with these priority areas in some cases; namely some of the C measures contribute as much to improving chronic disease management and follow up care as they do to workforce expansion and support. This report recognises this, by structuring the discussion of the C1, C2 and C3 measures based on their different components. This section is structured as follows.

The ICDP as a mechanism to tackle chronic disease risk factors, which includes an overview section and chapters relating to the A1, A2 and A3 measures (see below for a description of these measures).

The ICDP as a mechanism to improve chronic disease management and follow up care, which includes an overview section and chapters relating to the C1, C2,and C3 measures; Indigenous Health Project officer (IHPO) and Aboriginal and Torres Strait Islander Outreach Worker (ATSIOW) components as well as the B1, B2, B3, B4, B5 measures.

Workforce enhancements and supports for the ICDP, which includes an overview section and chapters relating to the C1 and C2 measures; Indigenous health service (AHS) enhancements, Aboriginal and Torres Strait Islander workforce, and ICDP Practice Manager components, as well as the C4 and C4 measures.

The appendices to this volume contain more detailed information relevant to each measure. These ‘measure appendices’ contain:

an assessment of the measure’s progress against the causal pathway;

an overview of the data available to the evaluation based on the Evaluation Framework;

an overview of the data sources used to inform the evaluation of the measure and the development of this report; and

additional material as required, including data appendices.

Executive Summary

This document is the Final Report for the Monitoring and Evaluation of the Indigenous Chronic Disease Package (the ICDP, or the Package). This report provides the final assessment of the implementation of the ICDP and its impacts between 2009-10 and 2012-13.

Overview of the ICDP

The ICDP aimed to reduce the incidence of preventable chronic disease and improve outcomes for Aboriginal and Torres Strait Islander people with chronic disease through 14 measures across three priority areas:[footnoteRef:2] [2: See Council of Australian Governments n.d., National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plans, viewed September 2012. ]

Tackling chronic disease risk factors;

Improving chronic disease management and follow up care; and

Workforce expansion and support.

These areas of focus and the individual measures were designed to address areas of priority need, including reducing chronic disease risk factors, and identified gaps in the current service system. The ICDP was progressively implemented from 1 July 2009 although some preparatory work commenced prior to this date. On 1 July 2014, the Indigenous Australians’ Health Program was established, consolidating four existing funding streams including the Aboriginal and Torres Strait Islander Chronic Disease Fund which had replaced the ICDP. The majority of the original ICDP measures are continuing under the new program.

Context

In 2008 the Council of Australian Governments joined in a National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.[footnoteRef:3],[footnoteRef:4] This agreement was particularly intended to contribute to the target of closing the gap in life expectancy between Aboriginal and Torres Strait Islander people and other Australians, within a generation.[footnoteRef:5] The overall agreement was to direct $1,577 million to this objective, including a Commonwealth contributing of $805.5 million.[footnoteRef:6] That Commonwealth contribution was implemented through the ICDP.[footnoteRef:7] [3: Council of Australian Governments October 2009, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, COAG (online), viewed 8 May 2014. .] [4: Council of Australian Governments [n.d.], Closing the Gap in Indigenous Disadvantage (website), COAG, viewed 8 May 2014. .] [5: ibid.] [6: Council of Australian Governments 2008, National Partnership Agreement on Closing The Gap in Indigenous Health Outcomes, COAG, Canberra. .] [7: Council of Australian Governments October 2009, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth. COAG, Canberra, viewed 8 May 2014. .]

In the period from 2005 to 2007, the gap in life expectancy between Aboriginal and Torres Strait Islander people and other Australians resulted in 1,523 potential years of life lost per 10,000 Aboriginal and Torres Strait Islander people.[footnoteRef:8] The substantial majority of that difference (79.7 per cent) was attributable to chronic diseases. [8: Australian Institute of Health and Welfare May 2011, Contribution of chronic disease to the gap in adult mortality between Aboriginal and Torres Strait Islander and other Australians, AIHW, Canberra, cat. no. IHW 48.]

Aboriginal and Torres Strait Islander people experience death from chronic disease earlier than other Australians, and chronic diseases were responsible for around three quarters of potential years of life lost in the 35 to 54 Aboriginal and Torres Strait Islander age group. Aboriginal and Torres Strait Islander people are also more likely to experience a potentially preventable hospital episode for a chronic disease than other Australians.[footnoteRef:9] [9: ibid.]

There are a number of behavioural risk factors that are associated with the chronic diseases most strongly affecting Aboriginal and Torres Strait Islander mortality: heart diseases; diabetes; diseases of the liver; chronic lower respiratory disease; cerebrovascular diseases; and cancers.[footnoteRef:10] Each of the six chronic diseases listed above is linked to one or more of the following behavioural risk factors: tobacco smoking; physical inactivity; alcohol misuse; poor nutrition; and obesity.[footnoteRef:11] [10: ibid.] [11: Australian Institute of Health and Welfare March 2012, Risk factors contributing to chronic disease, AIHW, Canberra, cat. no. PHE 157.]

Aboriginal and Torres Strait Islander people experience these risk factors at higher rates than other Australians[footnoteRef:12],[footnoteRef:13], which contributes to the elevated chronic disease morbidity and mortality experienced by them. [12: Britt H & Miller GC (eds.) 2009, General practice in Australia, health priorities and policy 1998 to 2008, Australian Institute of Health and Welfare, Canberra, General practice series, no. 24. cat. no. GEP 24.] [13: Australian Bureau of Statistics 11 April 2006, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS, Canberra, cat. no. 4715.0. ]

In spite of the high level of chronic disease and other morbidity among Aboriginal and Torres Strait Islander people, historically they have been lower users of primary health services than other Australians.[footnoteRef:14] This low level of primary care services relative to need in turn results in high use of hospital services, including emergency departments and outpatient clinics. [14: Council of Australian Governments October 2009, National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan, Jurisdiction: Commonwealth, COAG, Canberra, viewed 8 May 2014. .]

The reasons underlying the underutilisation of primary health care are complex. Certainly the social disadvantage experienced by Aboriginal and Torres Strait Islander people may contribute, as Aboriginal and Torres Strait Islander people will often have low levels of health literacy and lack the skills and knowledge required to negotiate complex pathways through the health system. Access to culturally appropriate health care can also be an important factor, given that Aboriginal and Torres Strait Islander people use mainstream general practices as well as Aboriginal health services (AHSs). Historically not all general practices have provided culturally appropriate services.[footnoteRef:15] [15: ibid.]

The Aboriginal and Torres Strait Islander population is also highly dispersed, and includes many people living in remote and very remote areas where access to services is inherently challenging. In urban and regional areas Aboriginal and Torres Strait Islander communities are often dispersed within large non Indigenous populations, which creates challenges around identifying priority patients, providing targeted programs to boost access to health services and improving care within a complex service system. [footnoteRef:16] Mainstream providers in these locations may also find it difficult to focus on improving services to Aboriginal and Torres Strait Islander patients when their target population includes a variety of disadvantaged groups. [16: In 2011, one sixth of the Aboriginal and Torres Strait Islander population was dispersed among large communities of 50,000 or more people and where the Aboriginal and Torres Strait Islander population comprised less than 2.5 per cent of the community’s population. Australian Bureau of Statistics 2014. Census 2011: RA by INGP counting persons by place of usual residence. Table Builder Basic (website), viewed 18 May 2014. .]

It is within this context that the ICDP was designed and implemented in a significant attempt to begin moving towards better and more equitable outcomes for Aboriginal and Torres Strait Islander people.

Monitoring and Evaluation of the ICDP

In July 2011, the department engaged the following consortium of independent consultants[footnoteRef:17] to undertake the monitoring and evaluation of the ICDP: [17: A fourth organisation, IPSOS Australia, was to have been involved in one aspect of the evaluation which did not occur as a result of a change in the focus of the evaluation.]

KPMG, the lead evaluator;

Winangali, an Indigenous communication firm, to support the community consultations for the evaluation; and

Baker IDI, to lead the health economics components of the evaluation.

The purpose of the evaluation was to monitor and appraise the implementation and impacts of both the ICDP as a whole and the measures that comprise the ICDP. The objectives were to assess the:

consistency of the implementation of the ICDP with the implementation plans;

extent to which the package and individual measures are consistent and coordinated with, and complementary to, each other and the ICDP aims (synergies among the measures);

appropriateness of the ICDP to the target population and stakeholder needs in terms of stakeholder awareness, appreciation and satisfaction with the activities undertaken under the ICDP; and

effectiveness of the ICDP in achieving the expected early results and in progressing towards achieving medium and long term outcomes.

A more focussed evaluation of the Local Indigenous Community Campaigns to Promote Better Health measure was also undertaken concurrently with this evaluation.

This national monitoring and evaluation was part of a broader strategy deployed by the department which also included:

the development of a monitoring and evaluation framework; and

the Sentinel Sites Evaluation project.

The ICDP Monitoring and Evaluation Framework[footnoteRef:18] was developed by independent consultants, and published in 2010. The Framework guided the Sentinel Sites Evaluation and this evaluation. The Framework is based on a program logic approach and identifies activities, outputs and expected results for each of the individual measures and the package as a whole over different time periods. Outputs are relevant to a ‘one year’ (and ongoing) time period, early results are relevant to a ‘two to four years’ time period, medium term results are relevant to a ‘four to 10 years’ time period, and longer-term results are relevant to a time period ‘greater than 10 years’. For each result, the Framework outlines key evaluation questions, the relevant indicators, data sources and timing of data collection. [18: Urbis 2013, Indigenous Chronic Disease Package Monitoring and Evaluation Framework, September 2010, Volumes 1, 2 and 3, Australian Government Department of Health and Ageing, Canberra.]

The Sentinel Sites Evaluation conducted by the Menzies School of Health Research was a place-based evaluation undertaken in 24 selected sites. It was mainly formative in nature and served two purposes:

to inform onthe implementation of the package, , and to identify barriers and facilitators to effective implementation as well as early outcomes at the local level at the local level; and

to provide this national evaluation with additional local data.

The national evaluation was both formative and summative. The formative evaluation activities monitored the progress of individual measures against their expected early results. The summative evaluation assessed the effectiveness of the ICDP in achieving its expected early outcomes and the likelihood of achieving expected longer term outcomes.

Findings: progress with implementation

The ICDP was designed to address weaknesses in the current primary health care system as well as encourage systems change by complementing as well as leveraging off existing initiatives. The evaluation found that most components of the ICDP were successfully implemented and that many of its operations are now well established and will continue to evolve.

The pre-existing Indigenous Health Partnership Forums (IHPFs) in each state and territory provided guidance and advice to the department, particularly early in the ICDP’s implementation. At the time the IHPFs included representation from the department, state and territory governments and the National Aboriginal Community Controlled Health Organisation (NACCHO) state or territory affiliate. In some cases the then State Based Organisation (SBO) of the Divisions of General Practice[footnoteRef:19] was also represented on the IHPF. In broad terms the Partnership Forums provide a mechanism for the partners to undertake joint planning and work to improve access to services as well as monitor progress and activities in relation to Aboriginal health in each jurisdiction. [19: SBOs and the Divisions of General Practice were no longer funded with the advent of Medicare Locals in 2011. ICDP funding was instead diverted to the Australian Medicare Local Alliance and to individual Medicare Locals.]

A number of national peak bodies were also involved in one of two ways. Some peak bodies participated in technical reference groups or advisory groups. Others were selected as recipients of ICDP funding to deliver an aspect of ICDP. In some cases, peak bodies fulfilled both roles, such as NACCHO and the Australian General Practice Network[footnoteRef:20] (AGPN). [20: The AGPN was effectively replaced by the newly created Australian Medicare Local Alliance in 2011.]

The specific findings are:

The ICDP implementation occurred largely as planned and nearly all components are now fully operational

This is a significant achievement given the scale and diversity of the ICDP, the considerable collaboration required and the need to be responsive in an evolving environment.

The ICDP implementation has resulted in:

deployment of a large, new workforce (direct employment of 521.3 FTE as at December 2013), and expansion of the existing workforce in all states and territories;

active engagement of over 200 communities in strategies focussing on chronic disease risk factors;

active participation by a large number of AHSs and general practices in initiatives to improve the management of patients with a chronic condition; and

mobilisation of a range of national initiatives that provide support to primary health care organisations and their staff to enhance their service delivery.

The ICDP has been responsive to implementation lessons, due to its supporting infrastructure and extensive collaboration between a range of stakeholders

The department established an operational infrastructure that enabled the ICDP to be responsive to implementation lessons as they arose. Mechanisms to monitor implementation and quickly identify when changes were needed operated throughout the evaluation period. These included reference groups, the Indigenous Health Partnership Forums, learnings from the Sentinel Sites Evaluation, this evaluation, and feedback obtained from the department’s program managers. The department used information obtained through these mechanisms to modify some aspects of the ICDP’s design and operations in order to strengthen its effectiveness.

Funded organisations also made changes to both their models and operations as they learnt what was working and what was not working so well. This reflects the willingness of these organisations to change and respond quickly to emerging issues.

The evaluation found that the changes made by the department and funded organisations in response to implementation lessons were necessary and have enhanced the potential effectiveness of the ICDP.

The ICDP implementation galvanised a large number of national and local stakeholders into a concerted and cooperative approach to improving services for Aboriginal and Torres Strait Islander people

The department used existing national and local structures to involve a large range of organisations in implementing the ICDP. The opportunity to be involved throughout the implementation and the shared commitment of these organisations to closing the gap resulted in close cooperation at the national and local level. Most notably, there were examples of the mainstream and the AHS sectors sharing resources and collaborating to improve services. This closer cooperation strengthened the ICDP’s implementation.

It took time for host organisations and the new workforce to get established

The ICDP funded a number of new workforce roles including the preventive health teams, Aboriginal and Torres Strait Islander Outreach Workers and Care Coordinators. The department anticipated that it would take time to establish this new workforce, and implemented strategies to assist in the establishment phase.

Implementation experiences indicated it was not only recruitment and training that took time. Once the staff were in place, it also took time for other organisations and the community to understand these new roles and for the staff to effectively engage with the community and service providers.

The ICDP successfully involved a large number of health care providers from the AHS and mainstream health sectors

The ICDP provided incentives for primary health care services and individual specialist providers to become involved in various closing the gap strategies. The effectiveness of the ICDP was heavily dependent on these organisations and individuals wanting to participate, and actively becoming involved in the strategies. The evaluation found that the ICDP signed up a large number of service organisations and individual specialist providers. This resulted in some providing services for the first time and others increasing their focus on providing services to Aboriginal and Torres Strait Islander people.

There is still scope to expand the level of participation while noting that some general practices and pharmacies do not have Aboriginal and Torres Strait Islander patients or are not able to participate because of the eligibility requirements (particularly small practices).

Community organisations welcomed the opportunity to develop their own, tailored community strategies to address chronic disease risk factors

The department had an overwhelming response from community organisations eager to develop and implement local community campaigns. These campaigns arose from a grass roots approach to preventive health that empowered and enabled community organisations to develop local solutions focused on local priorities. Community organisations were encouraged to develop partnerships with other organisations, including primary health services, as a strategy to build local capacity and enhance community members’ access to local health services. It has created an expectation in some communities that the campaign activities would continue even though ICDP funding was for a fixed period. Other organisations, recognising the fixed nature of ICDP funding, reported that they were seeking alternative funding sources to build upon what they were able to implement through the ICDP.

Findings: impacts on the health service system

The ICDP was designed to improve the capacity, capability and responsiveness of the primary health care service system to meet the needs of Aboriginal and Torres Strait Islander people. The evaluation found the ICDP has made progress with this objective although there are still opportunities, and in some cases an imperative, to further enhance these services.

Primary health care organisations have increased capacity and enhanced capability to provide appropriate services to Aboriginal and Torres Strait Islander people at risk of or with a chronic condition

The ICDP made a considerable investment in expanding the health workforce of the Aboriginal health and mainstream sectors that resulted in the direct employment of 521.3 (as at 31 December 2012) full time equivalent (FTE) staff. In addition, more of the existing workforce is providing services to Aboriginal and Torres Strait Islander people in areas of need.

This increased capacity of both the mainstream and the AHS sectors to provide chronic disease management and preventive health services to Aboriginal and Torres Strait Islander people had benefits including reducing the burden on GPs and other clinicians, improved referral pathways, reductions in patient no shows and enhanced preventative health capacity.

The ICDP also enhanced the capability of primary health care organisations through:

dedicated training opportunities – for example, 718 people (including 212 Aboriginal Health Workers (AHWs), 220 nurses, 82 allied health staff and 40 GPs) had received chronic disease self management training as at April 2013;

providing all staff in primary health care organisations with ready access to a rich array of resources that assist with chronic disease management through the creation of the Australian Indigenous ClinicalInfoNet;

increased access to education from specialist outreach providers; and

infrastructure grants to seven AHSs in four states to support their expansion of service delivery.

The establishment of new workforce types has created a need for ongoing skill development as these new roles continue to evolve. The evaluation found that staff employed in these new roles generally valued the training supports offered but there are training gaps which, together with other factors, have caused some staff turnover.

Some general practices are more attuned to the cultural needs of Aboriginal and Torres Strait Islander people

Many general practices were providing services to Aboriginal and Torres Strait Islander people but not necessarily ensuring that they operated in a culturally competent manner. The ICDP implemented a set of complementary initiatives, including cultural awareness training and recruitment of support staff, to encourage and support practices to be more focused on cultural aspects of patient need. The evaluation found that as a result, some general practices are more responsive to the needs of their Aboriginal and Torres Strait Islander patients.

The evaluation is not able to quantify the extent of these enhancements and considers that this is very much a work in progress outcome as not all general practices have fully embraced the need to change their patient management procedures, while others are still working through the practical steps to change these procedures. There was a perception from some stakeholders that the cultural awareness training requirements within the ICDP were inadequate, particularly for providers participating in the PIP Indigenous Health Incentive, both in terms of not all providers undertaking the training and that the minimum training requirement itself was not sufficient.

Community organisations are more oriented towards and are taking a more integrated approach to preventive health

Organisations participating in the preventive health components of ICDP clearly had a level of commitment to preventive health. For some organisations, the ICDP simply but importantly enabled them to consolidate and/or expand their existing efforts. For others, the ICDP enabled them to move from a programmatic approach to a whole-of-organisation approach to preventive health.

The extent to which preventive health became integral to, and was integrated within, an organisation depended on the prior experience of the organisation in preventive health, the extent to which organisational leaders viewed this as important and how quickly and effectively the teams themselves could establish internal working relationships.

The requirement for AHSs to have a smoke free workplace policy aimed to encourage a whole of organisation approach to preventive health.The evaluation found that the teams had an important role in assisting their organisations to implement this policy requirement, but they still faced considerable challenges to gain management support to enforce the policy.

Organisations have enhanced capacity and capability to develop and implement preventive health programs

For many primary health care organisations, this was the first time they had a dedicated workforce to specifically provide preventive health activities in the community to supplement any programs and activities they may have offered on their premises. In other cases, the establishment of the teams enabled existing activities to be undertaken in a more structured and strengthened form, and there were some organisations that used ICDP funding to continue existing activities.

There was a transfer of knowledge and skills from the preventive health teams to other health workers in the same organisation and the teams were able to leverage external resources. Thus the impact of the ICDP on the participating organisations reached beyond the immediate benefits of the direct investment in a new workforce.

New and enhanced existing partnerships between primary health care services and other community organisations strengthened the local focus on preventive health

Partnerships were often intrinsic in the development and implementation activities of the preventive health teams and local community campaigns. The type of partner organisations and the nature of the partnerships, varied from the funded organisation accessing external expertise during the development phase to cooperation around increasing referral and access to healthy lifestyle supports. These relationships were critical enablers but also increased the possibility of sustaining some aspects of the campaign after grant funding had been expended. The teams also liaised with a range of other organisations including state and territory health departments to ensure coordination of efforts within a region. Nearly all of the preventive health teams were working formally with other organisations or informally with staff in other organisations to create synergies and to support a consistent approach to preventive health locally.

Findings: impacts for Aboriginal and Torres Strait Islander people

The primary aim of the ICDP is to close the gap in life expectancy by ensuring that Aboriginal and Torres Strait Islander people have ready access to preventive health and chronic disease management services.

The evaluation found that Aboriginal and Torres Strait Islander people have benefited from the ICDP, particularly regarding enhanced access to preventive health measures which went some way towards addressing lifestyle related chronic disease risk factors. Increased access to primary health care and chronic disease management has also been demonstrated, although significant challenges remain. The evaluation was not able to quantify the extent of these impacts nor assess the extent to which organisations were successful in reaching those most in need.

The ICDP targeted the priority needs of Aboriginal and Torres Strait Islander people and substantially reached those in need of support

The ICDP targeted barriers that constrained people’s access to existing health services as well as expanding the availability of services. There is no single measure of reach for the ICDP, given the varying nature of its activities and whom they targeted. At the broadest level, the evaluation found that:

over 12,000 people in more than 200 communities actively participated in local community campaigns and many others engaged in preventive health activities through the efforts of the preventive health teams funded by the ICDP;

approximately 63 per cent (79,758) of Aboriginal and Torres Strait Islander people over the age of 15 and living with a chronic disease were registered at least once (between 2009 and 2012) by a primary health care organisation participating in the PIP Indigenous Health Incentive;[footnoteRef:21] [21: This estimate is derived from modelling rather than direct measurement.]

PIP IHI patient registrations continue to increase with 23.8 per cent more registrations in 2012 compared to 2011;

at least one in four Aboriginal and Torres Strait Islander people (145,167) received a PBS Co-payment subsidy between 2009 and 2012 when having their medications dispensed;

4,994 individual patients received services through the Care Coordination and Supplementary Services measure between October and December 2012; and

there was a rapid increase in the number of patients receiving outreach specialist and allied health services in regional and remote areas, with approximately 600 patient contacts per month during 2010-11 which increased to 5,449 patient contacts per month by December 2012.

Community attitudes about the inevitability of illness are changing

A significant challenge for the health workers engaged in the preventive health components of the ICDP has been changing community acceptance of chronic disease as a fait accompli. Helping Aboriginal and Torres Strait Islander people to identify chronic diseases as potentially avoidable is a key step to increasing participation in preventive health activities and utilisation of acute health services to help prevent the onset and progression of chronic disease. They made inroads but there is still a long way to go to shift the views of the community about the inevitability of chronic disease.

Individuals are better supported in their attempts to adopt healthier lifestyles

For individuals to successfully adopt healthy lifestyle behaviours, it is important for them to feel supported by the community, family and peers. The ICDP developed such supports through:

the delivery of community-based events and programs specifically designed to encourage family and peer groups to participate in preventive health activities;

the use of champions within local communities in campaigns and activities, where community identities acted as role models within their community and encouraged participants to engage in ICDP healthy lifestyle activities; and

the preventive teams conducting group support sessions, often in partnership with other organisations, for people wanting to change aspects of their lifestyle.

Community members contributing to various evaluation activities reported that they valued the supports, and that they felt more empowered to participate in healthy lifestyle activities as a result of these. This is consistent with the views of clinicians, who reported that ‘there has been increased interest from patients seeking support to quit smoking’.[footnoteRef:22] This in turn is likely to have contributed to an increase in the use of smoking cessation medicines.[footnoteRef:23] [22: Menzies School of Health Research 2013, Sentinel Sites Evaluation Report June 2011, prepared for the Australian Government Department of Health and Ageing, Canberra, p. 61.] [23: There was a 74.1 per cent increase in the dispensing of tobacco cessation medicines to Aboriginal and Torres Strait Islander people who had ever registered in the PIP Indigenous Health Incentive or supplied to AHSs through the Section 100 Remote Area Aboriginal Health Service (from 22,008 to 38,326) between the 24 month period preceding the start of the ICDP (July 2008 to June 2010) and the 24 months post-ICDP implementation (January 2011 to December 2012). This compared to an increase of 21.1 per cent for Aboriginal and Torres Strait Islander people who had never registered in the PIP Indigenous Health Incentive.]

Increased participation in preventive health activities and use of related supports has resulted in some individuals adopting healthier lifestyles

The adoption of healthy lifestyles often requires major changes to health behaviours that may be addictive, such as smoking and alcohol consumption, or strongly habitual, such as poor exercise and nutrition. As such, behavioural changes may not only take significant time to adopt, but may also require a large number of attempts before the desired outcomes are achieved. Due to the short period of time that many ICDP measures had been operating, it was not expected that significant changes to health behaviours would be identified during the evaluation. However, stakeholders did report a number of positive signs that some participants were actively attempting to adopt healthy lifestyles.

Many of those involved in delivering preventive health programs were cautious in suggesting that the ICDP had made a definitive change simply because of the time it will take and the level of on-going support required before there is a demonstrable reduction in risk factors.

Aboriginal and Torres Strait Islander people are making more use of services that lead to earlier identification of a chronic disease and improved assessment of their needs

The cumulative effect of a number of complementary aspects of ICDP measures has led to an increase in the use of services that are important in terms of the early identification of chronic diseases and related risk factors. They have also resulted in improved assessment of the patient’s needs for the on-going management of their chronic disease. Two broad strategies were built into the design of the ICDP:

initiatives that directly encouraged and supported a patient to make greater use their primary health care services, such as Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs) and the preventive health teams, and incentivising and supporting primary health care practices to register patients for the PIP Indigenous Health Incentive; and

initiatives that increased the capacity of primary health care services to undertake the relevant assessments such as (PIP Indigenous Health Incentive) incentive payments and restructuring of Medicare Benefits Schedule (MBS) item numbers, funding of additional staff and an increase in the provision of clinical specialist outreach services.

Specifically, the evaluation found that, as a result of these ICDP activities and other factors external to ICDP, there has been an 85 per cent increase in the number of Aboriginal and Torres Strait Islander Health Assessments (MBS Item 715) between 2010 and 2012.[footnoteRef:24] This was largely driven by an increase in GPs now providing this service, with a trend break coinciding with the ICDP’s commencement. [footnoteRef:25] [24: 2012 calendar compared to 2010 calendar year.] [25: Use of this item in 2012 was 44 per cent greater than expected when compared to the historical trend prior to the implementation of the ICDP.]

In addition, the increased use of outreach specialist services has contributed to improved initial and ongoing assessment of patients’ conditions, given that assessment was an important component of the care delivered by these providers.

The management of chronic disease patients has improved, but significant challenges for patients and providers remain

The ICDP adopted a multi-faceted strategy to improve the management of chronic disease patients. This included encouraging GPs to apply best practice chronic disease management, creation of a care coordination workforce, actively encouraging people to make more use of their health services, encouraging general practices to be more culturally appropriate and up-skilling the workforce to apply self management models of care.

There appears to have been some improvement in the coordination and management of chronic disease patients as a result of these initiatives, and consequently it is likely that the ICDP contributed to a reduction in exacerbations of chronic diseases and the onset of complications. The most notable examples are:

PBS Co-payment beneficiaries increasing their use of medicines;

increased access to specialist and allied health services;

provision of care coordination to Aboriginal and Torres Strait Islander people with complex needs. This, along with support from ATSIOWs, was associated with reports of increased access to services and a perception that people are receiving more coordinated care;

an increase in the use of General Practice Management Plan and Team Care Arrangement MBS items for Aboriginal and Torres Strait Islander people who had ever registered for the PIP Indigenous Health Incentive; and

some evidence that the quality of the services provided to Aboriginal and Torres Strait Islander people had improved.[footnoteRef:26] [26: Eighty seven per cent of Care Coordinators who responded to the ICDP evaluation survey (2013) agreed with this statement, as did eight six percent of health care professionals interviewed during the Sentinel Sites Evaluation (SSE) in 2012.]

There are however, some challenges that need to be addressed in future policy considerations. These include:

difficulty addressing the social determinants of health;

the capacity constraints of the care coordination workforce;

the relatively low use of the care coordination related MBS items that are being promoted through the PIP Indigenous Health Incentive;

the need to improve referral protocols to ensure that GPs appropriately refer patients in need of more intensive coordination; and

support and enhancing utilisation of self management models of care.

Future focus

The achievements of the ICDP are encouraging given the complexity of the challenge of addressing the prevalence and impact of chronic disease. Increasing levels of chronic disease necessitate a remodelling of modern health care systems, which are oriented to provide episodic rather than the integrated, patient centred care appropriate to chronic disease management. This type of system level change is by necessity incremental rather than transformative, and the ICDP can be viewed as an important step in that process.

The ICDP will continue to evolve as the new workforce evolves, as funded organisations better leverage complementary policy initiatives and the community becomes more engaged in the opportunities created through the ICDP. A number of implications have arisen from the ICDP that need to be considered in future policy decisions.

Considerations relevant to the implementation of future related strategies and initiatives

The organisations with a history in preventive health were able to more quickly implement their programs and campaigns, mostly because the ICDP enabled them to continue with what they were already doing or to expand upon existing programs. Others needed help and guidance and additional time to recruit staff, develop programs and engage with their communities. Future programs need to:

· ensure that the timeframes for implementation are adequate, recognising that often there is a developmental phase; and

· consider what national supports could be made available to local organisations.

Support structures (particularly for new and innovative programs) provided were critical during the development period, and continued to be valued throughout the evaluation period. These represent critical enablers and should be built in to the design of future programs.

Implementation of the ICDP illustrated that stakeholders need to understand the complementary nature of a multi-faceted strategy in order to realise the full potential impact. Therefore, future policy initiatives of the magnitude and complexity of the ICDP should have an effective communication strategy that establishes stakeholder understanding from the outset.

Considerations relevant to strengthening preventive measures

Preventive health needs to be seen as an integral part of comprehensive primary health care and requires strong leadership for there to be an optimal focus on this part of the care continuum. There is a need to further consider strategies that can assist primary health care organisations to embed a preventive health focus as part of their core business.

To realise change at the individual level preventive health programs must:

plan to provide on-going support which recognises the incremental nature of lifestyle change;

be empowered to supported to provide holistic support which recognises that chronic disease risk factors are inextricably linked to social and environmental factors; and

be able to effectively link individuals to other services to sustain engagement and change.

Considerations relevant to strengthening chronic disease management

In order to strengthen chronic disease management in the future, consideration should be given to:

shaping initiatives to directly and explicitly prioritise and incentivise patient outcomes in preference to broad based strategies;

further embeding the key features of the ICDP in existing structures and systems to maximise outcomes and ensure sustainability;

developing an integrated approach to building the capacity of individuals to manage their own health by linking activities like chronic disease self management and care coordination in a purposeful way; and

recognising that future planning needs to place team based models of care at the centre of initiatives aimed at improving chronic disease management.

Considerations relevant to workforce development

A structured and well-resourced approach to workforce development is critical to ensure that programs which are heavily reliant on workforce expansion are able to gain traction and progress past implementation goals to achieve the patient centred outcomes intended. Given the heavy workforce expansion component of the ICDP, a formal workforce strategy is required to ensure sustainability and to respond to the evolving roles of the new workforce.

Considerations relevant to monitoring and support

A number of inherent challenges were evident in the implementation of the preventive health components of ICDP. One related to the paucity of evidence about effective Aboriginal and Torres Strait Islander specific prevention initiatives that could be adopted by local teams. Further active and systematic generation of evidence is now required to support people in the field to undertake patient care and to inform the planning and design of future strategies. Successful implementation of initiatives which address barriers to access and improve the range and quality of care available will drive further demand. It is critical that this is monitored and that responsive plans are put in place to meet increased demand created by service system enhancements.

The evaluation of the ICDP demonstrated the challenges that primary health care services face in collecting the clinical and other patient-related data that is important to ongoing patient care. While the collection of data to support patient care is a challenge, there are clear benefits associated with service planning and improvement, and ultimately to patient outcomes. Supporting ongoing improvements in the collection and use of this data should be central to future initiatives aimed at improving chronic disease outcomes.

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0. Whole of Indigenous Chronic Disease PackageEvaluation of the Package

This chapter presents the evaluation findings regarding the progress and achievements of the Indigenous Chronic Disease Package (ICDP or the Package) as a whole. The ICDP was ‘framed as a package’[footnoteRef:27], not just a set of individual initiatives and as such, the whole of Package evaluation transcends evaluation of the individual measures which make up the ICDP, to consider: [27: Menzies School of Research 2013, op. cit., pp 50.]

the overall implementation success;

the appropriateness of the ICDP with respect to targeting identified need and addressing identified barriers;

the effectiveness of the ICDP in achieving expected outcomes in the short and medium termmade; and contributions it might make to longer-term Closing the Gap outcomes.

While the individual ICDP measures each have separate and specific aims, when viewed as a whole, the ICDP represents a strategy to augment and enhance the existing health care service system: to improve chronic disease prevention, care and management for Aboriginal and Torres Strait Islander people.

The ICDP was implemented within an environment of on-going change to the health system as a result of other Commonwealth initiatives and state and territory initiatives. Consequently, the evaluation also considered these influencing factors, both to explore the interplay between the ICDP and other factors and the potential contribution of these factors to outcomes that the ICDP was aiming to achieve (refer Appendix S – other influencing factors).

The evaluation of the whole of the ICDP draws heavily from the findings of the evaluation of the individual measures (using synthesis as the principal method of analysis). The contribution questions are addressed using the methodology provided in Appendix S of this report.

Implementation of the ICDP

This section examines the extent to which the implementation of the ICDP was successful in terms of:

whether it progressed according to the ICDP design and operational plan;

whether it had the linkages required to integrate with the broader health service system and health service developments rather than operating as a standalone initiative;

its responsiveness to stakeholder feedback; and

the extent to which it was reaching its target audience.

The section ends with a discussion of facilitators and barriers to achieving the expected early outcomes.

Progress against the ICDP plan

The implementation of the ICDP occurred largely as planned both in terms of its design and operations, with the majority of the ICDP being fully operational during the last period of the evaluation (2012-13). This is a significant achievement given the:

scale and diversity of the ICDP, which involved a large number of stakeholders;

considerable collaboration required at national, state and local levels across the mainstream and AHS sectors;

need to respond quickly to early implementation experiences; and

need to make changes in response to external influences such as the new health care reforms.

Where changes were made to the design or operational aspects of the ICDP, this was as a result of the practical experiences of the many stakeholders involved in implementing the ICDP. This reflects the responsiveness of the department and other stakeholders to ensure that the ICDP was relevant to individual Aboriginal and Torres Strait Islander people and that the ICDP was able to support the health service providers working to meet the needs of the Aboriginal and Torres Strait Islander community. This is discussed further in section 1.1.1.2.

The implementation of the ICDP was successful in terms of:

The deployment of a significant new workforce that created new and innovative roles within AHSs and in the mainstream primary health care sector as well as adding to existing workforce types (section 1.1.3.1 in this chapter considers this in more detail and chapter 5 investigates workforce as a thematic case study).

The creation of financial arrangements that provided significant benefits to patients (through the Subsidising Pharmaceutical Benefits Scheme (PBS) Medicine Co-payments (B1) measure) and enabled a large number of general practices to participate in the ICDP and to have a more purposeful and focused role in the care for Aboriginal and Torres Strait Islander people (through the Practice Incentives Program (PIP) Indigenous Health Incentive).

The mobilisation of a large number of mechanisms that support the workforce (training opportunities, improved access to chronic disease management resources and networking).

Improved collaboration and linkages across the health service system that was initially facilitated by the role of the Indigenous Health Partnership Forums (IHPFs) during the early stages of implementation and then further supported on an on-going basis by the national coordinating roles of the National Aboriginal Community Controlled Organisation (NACCHO) and the Australian Medicare Local (AML) Alliance and the local coordinating roles of NACCHO’s Affiliates and the Indigenous Health Project Officers (IHPOs).

Generating a greater focus on health promotion and preventive health within communities and within primary health care services.

A few aspects of the ICDP implementation were significantly delayed and the evaluation was not been able to assess these components:

A number of important changes were made to the Improving Indigenous Participation in health Care through Chronic Disease Self Management (B4) measure by Flinders University during 2013 in response to feedback by health care providers trained to apply the Chronic Disease Self Management (CDSM) model (refer chapter 3.5). This feedback, together with Flinders’ own assessment of the challenges faced by the trained health care workers, resulted in significant changes to the training tools, and the method of training. More importantly, changes were made to ensure that organisations whose staff were being trained had made a commitment to the implementation of the model within the organisation.

The Clinical Practice and Decision Support Guidelines (C5) measure involved the development of a web-based solution to provide health care providers easy access to a range of existing resources related to chronic disease management (refer chapter 4.5). The Australian Indigenous ClinicalInfoNet was launched by the Minister on 25 June 2013 and became publicly available from that date. Delays were due to several factors including the need to further redevelop some aspects of the product that was tested during an initial pilot phase, difficulties in getting a sufficient number of practices to participate in the pilot and the considerable time required to tender the final development of the product.

Areas where the ICDP continued to experience challenges were:

recruitment to some ICDP positions in some locations. Overall recruitment targets for ICDP positions were close to being met at the end of the evaluation period, however some recruitment issues were reported in some locations (for exemaple, remote areas);

retention, which remained an ongoing issue for the ICDP workforce, particularly in some of the newer roles such as the Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs) and IHPOs. This challenge reflects health workforce retention generally, particularly in rural and remote locations;

addressing the training needs of the newly deployed workforce, which was an on-going requirement and in some cases a challenge for organisations; and

encouraging a broader range of general practices to participate in the PIP Indigenous Health Incentive, and for those currently participating, encouraging them to provide the targeted services, given the still relatively low level of Tier 1 outcome payments (refer chapter 3.3).

These are further considered in the future focus section (refer chapter 1.6).

Responsiveness to stakeholder feedback

The ICDP received, and continues to receive, considerable support from the community, state and territory governments, peak bodies, and local primary health care services. This is not to say that that all stakeholders have at all times been satisfied with the design or implementation process. However, responsiveness to feedback from all levels was, and continues to be, critical to the successful implementation of the ICDP.

The experiences of those on the ground led to many suggestions for refinement that the department largely responded to. The Sentinel Sites Evaluation (SSE) played an important role in this regard as a monitoring and feedback device, as did national bodies su