Our Aim is to Improve the patient’s journey and access to comprehensive primary health care services to the Spinifex People in Tjuntjuntjara and thereby contribute to “closing the gap”: through

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• The delivery of  high quality evidenced-based comprehensive primary health care services in Tjuntjuntjara in an accredited primary health care service;

• Improving community access to an appropriate level of aged and disability services; and

• Building resources such as workforce, infrastructure and funding. 

The Spinifex Health Service provides a range of services in Tjuntjtuntjara including a youth program, a HACC program, and a primary health care service.  In addition, there is a suite of visiting services to support the primary clinical care being provided in the community.  A list of these services are contained in Table 1: Visiting Services.  As one of three communities supporting the Kakarrara Wilurrara Health Alliance (KWHA), an Alliance servicing related communities, SHS benefits from the ongoing clinical and allied services delivered by KWHA and through visiting specialist services from Western Australian clinical networks. 

Child health checks are now provided regularly up to school aged children and regular ear screening twice weekly at the school means that child ear health remains a priority and staff remain vigilant.

Service gaps remain in areas of GP time, community based renal dialysis, access to dietetic advice, SEWB, particularly young men, and health promotion.  Face to face GP time remains low – 3 days per month with the threat of this being halved with the potential cut of RFDS visiting services to the community.  The clinic continues to rely on RFDS for all emergency support with ongoing chronic care being provided by the KWHA visiting GPs.  This also means that health checks and GP management plans for patients with a chronic condition may not be up to date. 

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In recent times, links have been developed with community program deliverers in Kalgoorlie: Centrecare and Hope communities.  Regular visits are now being organised to support alcohol and drug programs and positive parenting and reducing family and domestic violence.  Further links will be explored to bring services to Tjuntjuntjara that would otherwise not be provided.

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Deliver high quality evidenced-based comprehensive primary health care services in Tjuntjuntjara in an accredited primary health care service;

 

In 2014, SHS received three year unconditional accreditation through GPA plus.  This was a key objective in previous plans and now provides the opportunity to maintain a high level of care underpinned by a culture of continuous quality improvement.  Over the next three years, the aim is to maintain a high level of care, continue a regular program of clinical and other audits and ensure the incident reporting system and consequent quality action plans remain current and are regularly reviewed.

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Key work being undertaken is the development of a comprehensive management plan for social and emotional wellbeing that can be reviewed and actioned by staff on the ground with supervision by a visiting psychologist.  SEWB remains a key issue for the community and to sustain a highly functioning community.  Therefore ensuring young men and women, particularly newly initiated young men remain connected to the community and continue to receive appropriate support and training drives the agenda for SEWB.

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SHS was also fortunate to have commissioned a dental unit in early 2014.  This facility now provides rooms for the visiting dental service equal to an urban service.  The dental service has proved to be valued by the local community with the visiting dentist receiving around 30 patient visits per four day visit.  Funding for this program is not secured and therefore maintaining this service and ensuring key infrastructure (the dental unit) is used,  is a key priority for the next three years. 

Increasing GP time in the community is also a key priority so that all community members undergo a health check within 12 months and all patients with a chronic condition have a regularly monitored and reviewed GP management plan and where necessary, a shared care plan.
 

Renal function remains a key health problem with the expectation that more people will have to leave the community to receive dialysis.  It is therefore important that these leaders of the community remain in the community and working actively towards community based dialysis with the options of either self care PD or CAPD or nurse led care being explored over the next 12 months. 

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There are still some gaps in the breadth of allied health services to be delivered with the need for at least one annual visit from a dietitian to advise on patient diets and HACC menus.

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Improving community access to an appropriate level of aged and disability services;

SHS has run a successful HACC program for around 25 clients since 2005.  However this cohort is aging and their needs are increasing.  Already several members have had ACAT assessment  indicating that there care needs are higher than can be provided through a HACC program.   In 2014, SHS has applied for aged care provider status with a view to applying for community packages for those community members who are been assessed by ACAT as requiring this higher level of need.  In June 2014, the HACC service underwent its first quality review for four years and this allowed the HACC service to consolidate its policies and procedures and set clear goals for the future service.    Changes in the aged care program in the state now means that clients are more likely to receive an ACAT assessment regularly and SHS needs to be in a position to respond to the HACC client needs.  Having aged care provider status means that more comprehensive care programs can be put in place and local community people can be employed to deliver these services. 

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Building resource such as workforce, infrastructure and funding for remote Aboriginal health service delivery

Resource development is key to building a high quality health service.  This means building the workforce, infrastructure suited to deliver the services and resources for service expansion.   The current clinic space has now outgrown the services being delivered.  The need to extend the current clinic to include additional training rooms and clinical spaces to cater to the increasing number of fly in fly out specialists and allied health services is now dire.  The extension remains contingent on excision of the Tjuntjuntjara community living area from the Great Victoria Desert Nature Reserve.    This is expected to occur this year.  This also affects any

plans for additional staff housing where the priority lies with housing for the female Aboriginal Health Worker and the newly recruited male trainee AHW.

 

Staff resource development remains a priority with training being planned for the trainee AHW to a certificate three Level and ongoing training for the AHP (female).  Mandatory training for the nursing staff include the Remote Emergency Care, and pharmacotherapy.  As well each is being encouraged to seek additional qualifications in their respective portfolios: child health and chronic disease. 

Other training being provided includes training for HACC Support workers, and youth work.  Over the next 12 months efforts will be made to employ a local male to run and youth program with the employed youth worker mentoring the person in that role. 

Tjuntjuntjara has an aging cohort of community members who currently receive HACC but are slowly needing more aged care support.  Expanding the range of aged care support that can be provided to the community remains a key priority for the coming years.  This will also mean more dedicated facilities for aged care and funding to expand the HACC and aged care remains a key priority for the next three years.  Independent living units for the aging population remain a key priority along with improved facilities from which HACC and other aged care services can be delivered.

Along with the aging population, increasing requirements for renal dialysis for community people is a major issue.  Facilities for community base dialysis will be pursued as a priority.  Key community leaders are being lost to the community when they are put on dialysis and this can mean the loss of traditional authorities in the community.   The maintenance of community cohesion as the social and emotional wellbeing of the community means that much more needs to be done to assist people to remain in their community for dialysis and where necessary for palliation.  Increasingly community people are choosing to remain on their lands to die and this means an increasing need for support and training for local clinical staff when that occurs.

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Summary: SHS PRIORITIES in 2014-2017:

 

• Increased GP face to face time

• Stable workforce that is involved in ongoing education and training

• A registered AHP and a male community member training to be an AHW.

• Increased focus on SEWB particularly for young men
  investigate the feasibility of a men’s shed program in the community.

• Introduce twice monthly men and women’s health promotion camps led by the male and female health worker with the CRC and the family Resource Centre

• Introduce Community based renal dialysis

• Set up male youth worker position filled by community person and supported/mentored  by youth worker

• Fund ambulance cover for the community

• Build Independent Living Units, increased facilities for aged care  and an expanded range of aged care services

• Dietetic service

• Maintain current levels of outreach services and include at least one Infectious Diseases Physician visits

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Aim:

• Provide 24 Hour emergency care  

Strategies:

• Maintain staffing levels for 24/7 on-call roster. Negotiate RFDS emergency support and retrieval.

• Ensure all staff have received REC training and/or ALS training and annual CPR updates.

• Apply for ambulance cover for all permanent residents at Tjuntjuntjara

• Apply for new ambulance for community

Who:

• Clinic staff

• SHS manager

Measure:

• There will be reduced staff turnover and turnover of locum staff will be minimised.

• Recruitment costs will be reduced. Salary costs will be reduced

• Mandatory training will be tracked and reported and all staff will have mandatory training included in the performance reviews

• All community residents have ambulance cover

• Grant in place for new ambulance

Funding source:

• DoH

• Lottery west

 

Aim:

• Maintain accreditation

Strategies:

• Implement regular audit process to ensure all patients receive optimum care

• Community population census carried out twice yearly

• Patient survey undertaken annually using an accredited survey tool

• Risk management system active and used by all staff

• Quality actions reviewed by staff on a regular basis.  .

Who:

• All Staff

Measure:

•  Audits are undertaken

• Incidents are reported

• Patient survey is undertaken

• Current patient population on the Communicare is current

• Quality action plan is dynamic

Funding source:

• DoH

Aim:

• Improve chronic disease management

• Improve early detection through timely completion of child and adult health checks

• Improve management of those with established chronic diseases
   

Strategies:

• Increase GP time to ensure all community members receive a health check

• Aim for 90% of all patients with a chronic condition have an active management plan

• Optimise nurse follow ups to ensure regular monitoring of the patients

• 80% of all relevant patients have a TCA in place.

• Weekly recalls are acted on promptly

•  a chronic disease are offered a GP management plan +/- a team care arrangement;

• Regular health promotion activities for men and women to provide education on chronic disease self management strategies

Who:

• Manager

• Chronic Disease Nurse

Measure:

• Employ GP for a period of time to ensure all health checks and GP management plans in place

• Engage ongoing GP time of at lest 5 days per month face to face

• At least 70% of current All community members have had a health check in the last 2 years

• 80% of all patients with a chronic condition have a GP management plan

• 80% of all relevant patients have a TCA

• There have been at least one trip per month organised for 10 months of the year

• Improvements in medication compliance

• Improvements in chronic disease self management

Funding source:

• DoH

Aim:

• Maintain visiting specialist services

Strategies:

• Review specialist needs

• survey GPs to assess requirements

• review identified needs against set program and seek funds for gaps

Who:

• Manager

• MD

Measure:

• All visiting services funded and reported on.  90% of patients requiring specialist review from visiting specialists seen during specialist visits.

Funding source:

• Rural Health West

Aim:

• Maintain better hearing better ear health

Strategies:

• Review ear cleaning program in schools

• Ensure regular audiology visits

• ENT telehealth in place for ongoing follow up

Who:

• Manager

• MD

• Child Health Nurse

Measure:

• Reduction in the number of pusy ears in the school

• ENT guidelines followed 100%

• Regular ENT telehealth sessions between doctor and ENT

Funding source:

• RHOF

Aim:

• Improved child health

Strategies:

• All school assessments and child health assessments undertaken when due.  Immunisations up to date.

• All pregnant women seen at least once in their first trimester and ongoing care in place

• Education sessions given to mothers with babies

Who:

• MD

• Child Health Nurse

Measure:

• At least 90% of all school aged children have undertaken as assessment in 2014/15

• All immunisations undertaken

• All pregnant women identified early and see midwife during both visits if in community

• The number of education sessions and the attendance at this sessions

Funding source:

• DoH

• WACHS

Aim:

• Reduce blindness in the community

Strategies:

• Continue ophthalmology/optometry visits in the community

• Continue Adelaide fly-ins for tertiary treatment for referred clients

• Participate in annual trachoma and trichiasis screening

Who:

• MD

• Manager

Measure:

• Visits undertaken by ophthalmologist and optometrist

• Flight organised for eye procedures in Adelaide
   

Funding source:

• DoH

Aim:

• Early identification of health issues in the community

Strategies:

• Regular meetings between the clinic and frontline staff to identify community members who may need help.

Who:

• All Staff

 

Measure:

• Reduction in active presentations, increase in preventive health

• Increase health promotion/prevention discussions with community

• Results off STI screening fed back to community

 

Funding source:

• DoH

Aim:

• Provide appropriate level of dental service

Strategies:

• Eight visits from dentist and assistant

Who:

• Manager

 

Measure:

• Funding secured for 2014/15 dental service

• Visiting dental trips all undertaken

 

Funding source:

• Oral improvement uni

• WACHS

Aim:

• Institute a tobacco program

Strategies:

• Consult with communities and identify those houses that would like to be tobacco free

• Put notices in identified houses

• Advertise what the notices mean and the importance of not smoking  around children

• Collect information on smoking status for all community members when the present at the clinic

• Institute brief interventions and offer smoking cessation courses to all patients who state they smoke as a first step

Who:

• All Clinical Staff

 

Measure:

• No smoking houses in the community

• Community aware of the dangers of smoking near children

• Smoking status reported on 90% of current patients

• Smoking cessation programs in place

 

Funding source:

• DoH

Aim:

• Continue current program for young girls

Strategies:

• Retain female youth worker position

Who:

• Manager

• Youth Worker

 

Measure:

• Regular activities reported

Aim:

• Regular home assessment in place to ensure safe environment

Strategies:

• Clinical staff to do annual home audits in those homes where HACC  clients reside

• Older people provided with information on how to stay safe in their home
   

Who:

• Nursing Staff

 

Measure:

• No home accidents experienced by HACC clients
   

Aim:

• Safe community environment for older people

Strategies:

• Paving in place going to those community locations frequented by older people

Who:

• Manager

• Project Manager

 

Measure:

• Paths completed to the satisfaction of the elders
  
   

Aim:

• Highly skilled workforce

Strategies:

• Performance reviews to be done annually and to including training plan.  Professional development program to be put in place for clinical staff

• Mandatory training to be monitored for all staff

Who:

• All  staff

 

Measure:

• All mandatory training undertaken

• At least 12 locally

• Clinical in-servicing calendar in place

• All staff have had their annual performance reviews and have training targets

 

Funding source:

• DoH

Aim:

• Clinic expansion planned

Strategies:

• Consultation with staff on clinic design

• Design and construct plans drawn and quoted

• Grant sought  for expanded clinic

Who:

• Manager

• MD

• Project Manager

 

Measure:

• Grant application accepted for expanded clinic

 

Funding source:

• DoH

Aim:

• Reduce staff turnover and costs of recruitment

Strategies:

• Recruitment is targeted and staff selected against current job description

• locum nursing positions filled with staff identified as suitable from past placements

Who:

• Manager

 

Measure:

• Reduction in recruitment costs

• All locum nurses known to the community

 

Funding source:

• DoH

Aim:

• Conduct IT security audit

Strategies:

• GPA plus audit undertaken

• Recommendations on improvements actioned

Who:

• SHS IT Project Manager

• Manager

 

Measure:

• Secure IT system as assessed by IT consultants

 

Funding source:

• DoH

Aim:

• Safe driving

Strategies:

• Mandatory four wheel driving training for all staff

Who:

• Manager

• Administrative Assistant

 

Measure:

• All staff identified as 4WD trained

 

Funding source:

• DoH

Aim:

• Safe driving

Strategies:

• Mandatory four wheel driving training for all staff

Who:

• Manager

• Administrative Assistant

 

Measure:

• All staff identified as 4WD trained

 

Funding source:

• DoH