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Posted: August 19th, 2023
Outcome Evaluation of the Effect of an Aboriginal Health Linking Information Database on Remote Area Discharge Planning
Outcome Evaluation of the effect of an Aboriginal Health Linking Information database on remote area discharge planning from metropolitan hospitals for Aboriginal patients living in the Pilbara and Kimberley regions of Western Australia.
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Intended Audience and Stakeholders
Outcome Evaluation Design, Methodology and Analysis
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Dissemination of Outcome Evaluation
Executive Summary
Outcome Evaluation of the effect of an information database on remote area discharge planning from metropolitan hospitals for Aboriginal patients living in the Pilbara and Kimberley regions of Western Australia.
Health outcomes of the Aboriginal population in the Pilbara and Kimberly areas of Western Australia are much poorer than non-Aboriginal populations and when looking at hospitalisations and emergency department presentations for these two regions, we see not only a large disparity between populations, but also a significant number of hospital patients have had to be treated in Perth. A web based Aboriginal health linking information tool in the form of a database was developed with the aim of improving the patient discharge process and the post-discharge patient journey for Aboriginal patients from Perth hospitals back to their remote homes. It will be trialed in the remotes Western Australian regions of Pilbara and Kimberley initially. Dependent on an outcome evaluation and understanding of the unintended consequences, it has the potential to be rolled out across Australia.
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Introduction and Background
A focus for Australian state and federal governments is to close the 10-year life expectancy gap between Aboriginal and non-Aboriginal Australians.1 Australia’s Aboriginal population have a higher burden of disease,2 reflective of both the social determinants of health, like their environment, social and economic disadvantage, in addition to deficient access to health services.3 Nearly two thirds of Western Australia’s Aboriginal people live in remote or very remote locations with limited health care and access to services.4 Both the Pilbara and Kimberly regions of Western Australia are considered very remote.
The Pilbara has a population of 66,298 of which, 15% are Aboriginal and there are twenty-six different spoken dialects.5 The Pilbara region represents approximately 20% of Western Australia’s land mass, covering over 500,000 km2 and is the second most northern region after the Kimberley. To put the size into perspective, it is almost twice the size of the Victorian state and nearly three times the size of the United Kingdom.5 The main industry of Pilbara is mining with most of the population living in Karratha, Pert Hedland and Newman.5 It has a very transient population of fly in/fly out workers, estimated to be 28,000 people in 2012.5 When comparing the non-Aboriginal population to the Aboriginal population, the Pilbara region has a higher proportion of females and a younger age structure, 80% are aged 45 and under.6 However, as an overall population, it has a 5% higher proportion of male residents than the state average of 51%.6
The Kimberley in 2013 had a population of 39,890 of which, 44% are Aboriginal and spread over one hundred communities with fifteen different dialects spoken.7 It is the state’s most northern region with an area of 424,517km2. Broome, Kununurra, Derby, Wyndham, Fitzroy Crossing and Halls Creek is home to most of the population.7 It also has a large transient population due to mining being its largest industry. The Kimberly, similarly to the Pilbara, has a younger age structure of Aboriginal population compared to non-Aboriginal and has a higher level of disadvantage compared to other regions.8
Along with poorer health outcomes and high levels of social and economic disadvantage compared to non-Aboriginal populations in these two regions2 a disparity also exists when looking at hospitalisations and emergency department presentations for these two regions. A significant percent of patients are treated in Perth hospitals, which can be financially costly on the health systems and an imposition on Aboriginal patients and their families.
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2003- 2013 Hospitalisations for 15-64 years
The Pilbara had 71,806 (120,785 per 100,000) hospitalisations. This is six times higher than the non-Aboriginal population in Pilbara and 10% higher than the Aboriginal state rate.6
The Kimberly had 155,544 (142,413 per 100,000) hospitalisations, which is six times higher than the non-Aboriginal population in Kimberly and 28% higher than the Aboriginal state rate.8
2013/2014 Emergency Department Attendances
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The Aboriginal population made up 30% of the overall Pilbara hospital emergency department attendances with 59,233 in total. Of that 30%, 25% of Aboriginal patients were transported to attend emergency departments of Perth hospitals.6
While in the Kimberley, Aboriginal emergency department attendances was 59,233, representing 57% of all attendances with 17% of Aboriginal attendances needing to be seen at Perth hospital’s emergency departments.8
With both the Pilbara and Kimberley regions comprise a large area with a relatively low population within, it creates a challenge for the delivery and accessibility of health services. Evidence supporting increasing disparities in post-discharge health outcomes 9-11 is suggestive of a tool needed for better discharge planning that considers the cultural needs of the Aboriginal people as well as understanding of the logistical complexities.12 The overall implications of suboptimal discharge processes impact on patients and health workers. Negative impacts can include but are not limited to, more staff time spent making patient arrangements, delayed discharge for the patient, inconsistent and poorly coordinated transport schedules leading to long delays, reduced provision of care in the community, additional and often unnecessary trips and hospital admissions that could be avoided.13,14
To address some of these problems, a web based Aboriginal health linking information tool in the form of a database was developed with the aim of improving the patient discharge process and the post-discharge patient journey for Aboriginal patients from Perth hospitals back to their remote homes. It will initially be trialed in the remote Western Australian regions of Pilbara and Kimberley. Dependent on an outcome evaluation and understanding of the unintended consequences, it has the potential to be rolled out across Australia.
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Figure 1. Geographical representation of the Pilbara and Kimberly regions of Western Australia and the distance from Perth. 15
Program Summary
The current discharge processes for Aboriginal patients returning to remote areas in the North of Western Australia, specifically the Pilbara and Kimberley regions, are impacted by a lack of readily accessible local information to metropolitan-based health workers. Without an understanding of the resources, geography, services and other factors relevant to post-discharge support and management, metropolitan-based health workers are not able to make effective and efficient discharge plans which may result in either poor care and follow up, or patients having to staying in Perth longer than necessary, away from their families and at additional costs.
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Figure 2 shows a schematic representation of the current situation which utilisation of the database aims to improve. A secondary outcome of the evaluation may identify areas of improvement that can enhance the success of the program. If this evaluation demonstrates that the program is successful, the scope of the program could be expanded to include other regional and remote locations across Australia.
Figure 2. Schematic representation of the problem to be addressed in this evaluation
The following case example highlights the need for better information at the time of discharge and demonstrates the impacts on the patients and their families.
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Case Example
Joe* is a 47-year-old Aboriginal male who resides in Swift Bay, 120 kilometers west of the Kalumburu Aboriginal Community in the Kimberley area of Western Australia. He underwent vascular surgery at the Fiona Stanley hospital in Perth and was ready for discharge. His surgeon requested a follow review in 2 weeks and suggested he should remain in Perth until his follow up appointment time. Joe and his wife were staying in a Perth hotel near the hospital, when they received word that one of their relatives had passed away. Aboriginal people place great importance on the cultural practice of ‘sorry business’, where a whole community comes together to share the sorrow.16 Joe and his wife left Perth the day before the review appointment. Another follow up appointment was made in 3 weeks’ time, requiring Joe and his wife to make the 24-hour journey back to Perth and accommodation was required for 4 days pending return travel arrangements. They could have had follow up with a visiting cardiologist from Perth via telehealth conferencing at their local hospital, which would have been a 4-hour same day return trip using local transport.
* name changed for privacy reasons
The Evaluand
The evaluand is a database portal that is accessible to metropolitan-based health workers 24/7 containing information regarding the availability of funded medical and support services within the Pilbara and Kimberley regions. It will provide information on location and operating hours of community pharmacies, local hospitals with telehealth facilities, visiting specialists schedules, nursing availability and skills, along with relevant and practical information such as seasonal weather, road conditions during seasons, travel times and distances between communities and services. The inclusion of aspects of cultural aspects is collaborative and aims to include information on sacred sites, significant exclusion times and areas where applicable and available. It is understood from conversations with Aboriginal Health Liaison Officers (AHLO) that some information may not be included due to cultural sensitivity, thus this could be considered a limitation of the database information.
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Training of hospital clinicians and AHLO staff would be undertaken so that discharge planning is synergistic and utilises the intimate local area knowledge of the AHLO’s to maximise efficiencies and patient experience. Access to this database at the point of discharge planning aims to facilitate more informed and streamlined plans which can support discharge decisions to return patients to remote areas or to accommodate them in Perth until they are well enough to return to their home.
Program Logic
The program logic model below demonstrates the logical linkages among the program resources, the outputs (activities and audience) and short, medium and long-term outcomes17, in consultation with the stakeholders about the strategies and chain of events that need to occur to accomplish the goals and objectives of the database implementation. During the evaluation process, it will be used as guide to define what is done and how success of the outcomes will be measured in addition to providing an opportunity to identify areas of improvement.
It is read from left to right and starts with the inputs defined as the resources needed for the project. It then moves to outputs which show the activities, processes, tools and events to bring about the intended changes and results of the database usage. The participation column shows the people who will use the database and participate in the activities. The outputs are the product of the program activities. Outcomes are the expected changes that result from the program’s activities and range from short to long term results. Short term outcomes are the most immediate changes, evidenced in learning and knowledge of the database use and practicalities. Medium term outcomes are the changes in the behaviours and practices because of the increased knowledge and awareness of the database and used in the discharge planning process. Long term outcomes are the conditions that change as a result of the actions of the users and in this case effect the end user. 18,19
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Purpose of the Evaluation
It is the intention of this evaluation to determine whether the database program meets the aim of improving hospital discharge for Aboriginal patients returning to the Pilbara and Kimberley after receiving treatment in Perth metropolitan hospitals. An improvement would be identified as a reduction in treatment and transport and better patient experiences. The outcome evaluation will be a mixed method design, using qualitative and quantitative data as the most appropriate methods given the timeframes and budget constraints.
A secondary outcome of the evaluation may identify areas of improvement that can enhance the success of the program. The significance of the evaluation is instrumental in that if the program demonstrates tangible improvements to the patient experience, streamlines the services and consequently delivers cost efficiencies, then the scope of the program could be expanded to include other regional and remote locations within Australia with further interstate transferability.
Intended Audience and Stakeholders
This mixed methods outcome evaluation is commissioned by the Government of Western Australia Health Department who will be the recipient of the full evaluation report. Other stakeholders and their interests are:
- Aboriginal Health Council of Western Australia – a peak body that represents 21 Aboriginal Community Controlled Health Services across Western Australia.
- St John Ambulance Australia – provider of high quality ambulance and first aid services.
- Lions Eye Institute – non-for-profit organisation using scientific research and clinical practice in the prevention of blindness and eye diseases
- Australian Medical Association – The Australian Medical Association is the professional association for Australian doctors and medical students.
- Royal Flying Doctor Service – extensive primary health care and 24-hour emergency service to those who live, work and travel throughout Australia.
- Primary Health Works (Country WA) – support organisation for primary health providers – GPs, allied health professionals and community services to provide efficient and effective medical services to patients, particularly those at risk of poor health outcomes.
- Aboriginal Medical Service – health service for Aboriginal people in Perth metropolitan area.
- Aboriginal Health Liaison Workers – provide support services including travel, transport and interpreters to assist Aboriginal patients through the care and discharge process in a culturally informed and respectful manner.
- Aboriginal Health Workers – Play a vital role in the primary health care workforce, providing clinical and primary care for individuals, families and community groups.
- Western Australian Country Health Service – provides accessible health services to the regional population and a quality health care workforce.
Key Evaluation Questions
- Have discharges of Aboriginal patients returning to remote locations (Kimberley and Pilbara) improved following the commencement of the database system?
- Have there been any unintended consequences of the program?
- To what extent have discharge planning processes changed?
- What is the patient experience?
Outcome Evaluation Design, Methodology and Analysis
Table 1 below represents the design and methodology of the outcome evaluation. It details what and how the outcomes are being evaluated and the types and process of gathering information data for analysis.
This type of study is descriptive with a mixed method design to assess the service utilisation of the database and to gather the views of both direct user and recipient of the services the database was designed to assist in the patient discharge process for Aboriginal people living in the Pilbara and Kimberly regions of Western Australia.
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The methodology used will be both quantitative and qualitative by way of self-report surveys, quizzes with users and focus groups with groups involved in the discharge process and by yarning with Aboriginal patients. Due to time and budget restraints, each group will be a representative sample of the wider group of users and recipients.
Purposive sampling will be done in that with some key outcomes, certain people will be selected representative of the wider users and selected patients who have experienced the discharge process using the database to arrange their post health care will be interviewed.
Quantitative measures will be the analysis of key database usage statistics broken down into type of health person, number of use, length of time of use and other key broad metrics. These will be statically analysed using t-tests and correlations comparing information gathered at baseline (assumption of no knowledge), one month after database introduction and use and again at 3 months after inception and use. Quantitative data results will be presented as tables, graphs or charts.
Qualitative data will be presented as descriptive themes in the final report of the outcomes evaluation and presented to key stakeholders.
Table 1: Outcome Evaluation Design: Mixed Methods (Quantitative and Qualitative)