Follow-up care and medication access has been improved and readmission rates reduced for Aboriginal and Torres Strait Islander cardiology patients after a new program started at Princess Alexandra Hospital (PAH).
The Better Cardiac Care project is only halfway through its three-year trial but it is already seeing outstanding results, providing culturally-appropriate support to more than 230 inpatients and 600 outpatients since mid-2015.
Clinical Nurse Consultant Vivian Bryce said the project was focused on improving access, support and health knowledge for Aboriginal and Torres Strait Islander people.
“This project is responsive to Aboriginal and Torres Strait Islander people’s cultural needs as well as their clinical needs, and supports their journey from hospital to home,” Vivian said.
The Better Cardiac Care multidisciplinary team conducts daily rounds, visiting inpatients and outpatients attending appointments.
“During a patient’s stay, we help coordinate their care and ensure they understand what their care plan is,” Vivian said.
“A major part in improving patient health literacy has been our TRACS [Transition Report Acute to Community Service] document.
“We sit with each patient and write down in their own words what’s happened to them while they have been in hospital, so that it improves their understanding on the care they receive and any further follow up that may be required.”
The project also involves a medication trial, with patients receiving a week’s worth of medication upon discharge if they are already registered for the Closing the Gap Pharmaceutical Benefits Scheme (PBS).
“A lot of our patients are registered for Closing the Gap PBS, however, they normally wouldn’t have access to this when being discharged form hospital,” Vivian said.
“We give them a seven-day supply of medication, under the PAH Closing the Gap medication trial, and then link them with a GP and the PBS—this ensures their treatment is consistent from discharge.”
Over the last year, post-discharge follow-up GP appointment attendance had increased from 46 per cent to 89 per cent.
Readmission rates were also declining, with less than 10 per cent of Better Cardiac Care patients readmitted compared to 24 per cent hospital wide.
“Building connections back to community is vitally important for a patient’s health, we have been working hard, partnering with GP services to ensure better quality community follow-up and to lower the rate of readmission to hospital,” Vivian said.
Statistics and figures aside, Vivian said the real indicator of the project’s success was individual patient stories and feedback.
“So far the feedback is remarkable, our patients feel like they are well supported in the hospital system,” Vivian said.
“We have also seen some incredible individual outcomes, including one young gentleman who had previously discharged against medical advice, was really sick and at risk of permanently disengaging from the healthcare system.
“Because of the extra support we put in place he’s gone from being in his 40s needing surgery on his heart, to having surgery, recovering and now being a productive member of the community—that was a great end point.”
The Better Cardiac Care project multidisciplinary team consists of two clinical nurse consultants, a pharmacist, hospital liaison officer and administration officer, and a cardiologist.
The project was also physically transforming the PAH, with beautiful Aboriginal and Torres Strait Islander artwork placed throughout the hospital to create a culturally welcoming environment for Aboriginal and Torres Strait Islander patients.