Best practice primary and secondary preventative interventions in chronic disease in remote Australia

People living in remote Australia have a much higher prevalence of chronic disease and significant variation in interventions delivered when compared with urban dwellers. These largely include variations in medicines for asthma, chronic obstructive pulmonary disease and Alzheimer’s disease; and significant variations in hospital admission rates for heart failure and diabetes related lower limb amputations.
In March 2017, the Australian Commission on Safety and Quality in Health Care contracted Barbara Schmidt and Associates to undertake a consultancy to identify and describe successful strategies that effectively implement best practice primary and secondary prevention services for patients with chronic disease in remote Australia. The methodology consisted of a literature overview, consultation with key stakeholders in remote Australia, collation and analysis of materials and a written report.
The literature overview identified a number of successful interventions for effective primary prevention of chronic disease. These include existing child, adult and older person’s health checks, immunization programs, and healthy lifestyle programs for smoking, nutrition and physical activity. Best practice secondary prevention initiatives were also identified in the literature, these include: several best practice clinical chronic disease guidelines and care planning instruments for chronic disease management in remote areas; studies into diabetes management specifically the Getting Better at Chronic Care project in north Queensland, the ABCDE Project in the Northern Territory and the Kimberley Aboriginal Medical Service Retinal Screening Program(1-3). While a number of other initiatives were also identified, there is limited published literature on successful initiatives, and many of those identified were found to no longer being delivered in remote communities. This may be due to common issues found in remote Australia such as the initiative being a pilot program, defunding of the initiative, the person who championed it has left, or the program outcomes have not been published.
The consultation process consisted of – a roundtable discussion forum (n=12) held in Cairns to align the participants from the National Rural Health Conference, and a remote consultation process (n=15) across five states. The roundtable assisted in identifying several best practice examples of primary and secondary prevention services in remote Australia, and in identifying key stakeholders for the interviewing process. The conference presentations were also targeted to identify new initiatives in primary and secondary prevention in remote Australia.

The consultation findings revealed that for success any initiative must reflect features of the Chronic Care Model (4). Successful primary prevention strategies had the following features -collaboration with several communities based agencies usually external to the health services, a partnership approach, and a focus on the social determinants of health. These features contribute to the sustainability of initiatives. Two successful primary prevention initiatives were reported to demonstrate these characteristics. The first is the Food Ladder, a food security and social business model, being conducted in Ramingining and Katherine in the Northern Territory. In the first 6 months of operation in Ramingining a 5% increase in the sale and consumption of fruit and vegetables is reported. The second is a successful health promotion model – the Be Heathy and Safe Maranoa Project – from Roma in Queensland, whereby the regional council is the first stop and coordinator for all health promotion initiatives in the shire.
Three successful and well embedded secondary prevention models were identified in the consultation process that demonstrate how a change in service delivery design can improve access to services to manage chronic disease. The three successful models were:
1. Central Australian Aboriginal Congress (Congress in the NT – shows how a decentralised model of care based on population numbers, better use of infrastructure, and a redefinition of service delivery roles improved screening and care planning.
2. Generalist Physician Outreach Model in Katherine in the NT – demonstrates how a general physician model of specialist service delivery integrated into primary health care service delivery improves continuity of care; and
3. Telehealth model in central Western Queensland – demonstrates another way to provide access to specialist services for remote people, to avoid patient travel, improve appropriate screening, prevent hospitalisations and manage a chronic condition using best practice guidelines.
Four examples where clinical patient information systems were identified to demonstrate best practice clinical decision support and the importance of using a systematic approach to chronic care, including: electronic patient records; practice management; care planning and recall systems; medication management; and secure referral processes. Kimberley Aboriginal Medical Service uses MMex as their corporate system for a network of eight community controlled health services in Western Australia. The Northern Territory Government uses the Chronic Conditions Management Model as a systematic and integrated approach to prevent and manage chronic disease by streamlining systems to improve coordination, integration, delivery, documentation and evaluation of chronic disease care. Over four years these changes have led to almost a doubling in care planning for patients to 61%, with nearly 96% of diabetic patients having had a HbA1C recorded in the past year as well as a reduction in preventable hospitalisations. Another information system identified was MedicineInsight being used in rural Tasmania, that promotes quality improvement in GP prescribing whereby they can compare their prescribing with other GPs at local, regional and national levels.
Nganampa Health Service in Central Australia found that having a dedicated chronic disease program manager who provides ongoing professional development for staff and measures compliance with clinical protocols for chronic disease prevention, has contributed to a reduction in emergency evacuations by 57% in the past year. Maari Ma Health Service Aboriginal Corporation in Broken Hill uses a hub and spoke model to deliver a comprehensive coordinated primary care strategy in the Far West Region of New South Wales. The key features of the strategy include: client focused delivery of care; quality improvement; and population health approach to address risk factors across the continuum. In the past five years this has resulted in a ten-fold increase in screening, almost 80% of clients have a care plan and there are reported improvements in blood pressure control.
The overarching finding of this study is that a systematic approach to chronic disease prevention and management is critical for success. The main enablers for success to improve primary prevention are to ensure: that any intervention is embedded into the social fabric of the community; strong partnerships are developed to empower the community, recognising that these are often found outside the health sector; intervention(s) are tailored specifically to each remote community; targeting screening for different age and gender groups; and having sustainable long term funding to support initiatives that should build on the social determinants of health.
To improve secondary prevention interventions the enablers are to: use a system approach to chronic disease care; redesigning health services to implement the chronic care model and maximize Medicare billing for ongoing resourcing; and embedding continuous quality improvement into the culture of service planning, monitoring and evaluation to ensure chronic disease is ‘everyone’s business’. This will involve having a clear blueprint for service development, actively engaging with clinicians, investing in training and supporting the workforce, having and ensuring all practitioners use the same clinical information and decision support system, proactively supporting telehealth and ensuring all initiatives and staff understand the construct of the community in which they serve.