“You Can’t Work with My People If You Don’t Know How to”: Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease

Ilse Blignault, Liz Norsa, Raylene Blackburn, George Bloomfield, Karen Beetson, Bin Jalaludin and Nathan Jones
Additional contact information
Ilse Blignault: Translational Health Research Institute, Western Sydney University, Penrith, NSW 2751, Australia
Liz Norsa: Translational Health Research Institute, Western Sydney University, Penrith, NSW 2751, Australia
Raylene Blackburn: South Western Sydney Local Health District, Liverpool, NSW 1871, Australia
George Bloomfield: South Western Sydney Local Health District, Liverpool, NSW 1871, Australia
Karen Beetson: South Western Sydney Local Health District, Liverpool, NSW 1871, Australia
Bin Jalaludin: South Western Sydney Local Health District, Liverpool, NSW 1871, Australia
Nathan Jones: South Western Sydney Local Health District, Liverpool, NSW 1871, Australia

IJERPH, 2021, vol. 18, issue 14, 1-17

Abstract: Indigenous Australians experience significantly poorer health compared to other Australians, with chronic disease contributing to two-thirds of the health gap. We report on an evaluation of an innovative model that leverages mainstream and Aboriginal health resources to enable safe, supported transfer of care for Aboriginal adults with chronic conditions leaving hospital. The multisite evaluation was Aboriginal-led and underpinned by the principles of self-determination and equity and Indigenous research protocols. The qualitative study documented processes and captured service user and provider experiences. We found benefits for patients and their families, the hospital and the health system. The new model enhanced the patient journey and trust in the health service and was a source of staff satisfaction. Challenges included staff availability, patient identification and complexity and the broader issue of cultural safety. Critical success factors included strong governance with joint cultural and clinical leadership and enduring relationships and partnerships at the service delivery, organisation and system levels. A holistic model of care, bringing together cultural and clinical expertise and partnering with Indigenous community organisations, can enhance care coordination and safety across the hospital–community interface. It is important to consider context as well as specific program elements in design, implementation and evaluation.

Keywords: indigenous health and wellbeing; holistic health; healthcare innovation; cultural competence and cultural safety; Aboriginal; chronic disease; hospital; discharge; urban; program evaluation (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2021
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (1)

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