CKD Services to Aboriginal People
Providing Chronic Kidney Disease (CKD) Services to Aboriginal and Torres Strait Islander People.
North Coast Area Health Service
Abstract
The Renal Case Manager (RCM) identified an underrepresentation of Aboriginal patients on the CKD program, resulting in higher rates of urgent start dialysis. Investigating existing culturally appropriate programs lead to participation in the Goori Diabetes Complications and Assessment Clinics (DCAC). The clinics assess for diabetes and complications of diabetes including CKD, in partnership with the Aboriginal Medical Service (Thomas, 2007b). The CKD Nurse Practitioner is now receiving referrals from the clinic for patients identified with CKD to prevent disease progression (Thomas, 2007a). Ongoing patient management involves collaboration between Primary Health Services and the Richmond Network Renal Service. In the last 12 months, 38 patients have been referred to the CKD program with a subsequent reduction in hospital admissions for anaemia. State funding has been allocated for similar collaborative approaches.
Aim
To provide culturally appropriate CKD services to the Aboriginal & Torres Strait Islander population in the Richmond Network in collaboration with primary and community based services to prevent disease progression (Thomas, 2007).
Nature of the Problem
Diabetic nephropathy is the leading cause of kidney disease in Australia (McDonald, Chang and Excell, 2007a). Type 2 Diabetes Mellitus is the highest cause of indigenous Australians on renal replacement therapy (i.e. dialysis or transplant) (McDonald, Chang and Excell, 2007b).
The report of the Chief Health Officer identifies that the onset of diabetes occurs earlier among Aboriginal people, and leads to a greater burden of illness, including kidney damage (PHD, 2008).
Collaboration between Renal Services and community based Aboriginal Medical Services is required to ensure early detection and management of chronic renal disease to limit disease progression.
Extent of the Problem
Dialysis rates are increasing nationally, particularly for Aboriginal and Torres Straight Islander people (McDonald, Chang, and Excell, 2007c). The national Urgent Start dialysis rate is for Aboriginal people is 37% compared to 25% for the rest of the population (McDonald, Chang and Excell, 2007b).
While almost 12% of the dialysis population in the Richmond Network in 2007 were of Aboriginal and Torres Strait Islander descent, they represented only 2% of people on the CKD program. Thus early detection and management was not occurring.
The challenge for the RCM was to improve early referral rates into the CKD program through the development of a CKD management program appropriate to the needs of the community (Thomas, 2007).
Strategic Importance
This project links to NSW Health Strategy 3, strengthening primary health and continuing care in the community. The partnership between the DCAC and the Richmond Network Renal Service provides Aboriginal and Torres Strait Islander people with accessible early diagnosis of CKD and with interventions to improve their health (Thomas, 2007b). Unnecessary admissions to hospital can be avoided, including those for anaemia and urgent start to dialysis (Thomas, 2007a, Roger, 2005). The program supports the goal of keeping people healthy through the delivery of well managed, high quality, relevant and appropriate care (Oxfam, 2007).
Planning & Implementation
The Aboriginal Vascular Health Program is a holistic approach to managing CKD (NSW Department of Health, 2002). Discussion commenced with the Aboriginal Medical Service (AMS) in Casino to identify possibilities for CKD nurse input. The RCM provided in-service to the AMS staff on dialysis therapies and NCAHS renal services using Aboriginal Vascular Health Program resources.
The RCM was invited to attend the monthly DCAC. At the DCAC, the RCM collects blood for pathology assessment, and provides CKD management information at the Case Conference at completion of assessment at every clinic. Documentation of the clinic outcomes is then sent to relevant community, primary and specialist services with recommendations for ongoing patient care (Cooper et al, 2007).
A CKD Nurse Practitioner (NP) role was subsequently implemented in the Richmond Network to manage referrals from the DCAC clinic.
On average, 25 patients are seen each DCAC, with approximately 25% of patients referred to the CKD NP. CKD Assessment Clinics occur at community health sites and the Casino AMS. Regular monitoring of patient symptoms, education on dialysis options, coordination of medication therapy, and feedback to General Practitioners and the Nephrologist is provided.
As kidney disease progresses the patient is referred from the CKD NP to the RCM. The RCM provides assessment, education and referral to the multidisciplinary team to plan for dialysis therapy. The trusting rapport developed at earlier clinics assists the patient’s decision-making regarding hospital treatments and dialysis options (Oxfam, 2007).
Outcomes & Evaluation
Creating a partnership with the AMS and community based services has resulted in the development of a culturally appropriate CKD service. Referrals have been received by the CKD Nurse Practitioner from every DCAC. A total of 38 patients with previously undetected CKD have been referred to the CKD NP. Four patients have been referred to the RCM for pre-dialysis education and management. Dialysis planning and education allows for the possibility of home dialysis therapy for Aboriginal and Torres Strait islander people.
Admissions to hospital for anaemia, fluid overload and urgent start to dialysis have been avoided. Patients continue to be managed by their usual health care providers, as outpatients at Aboriginal Medical Services and community health, in collaboration with the Renal Service. The program supports the goal of keeping people healthy through the delivery of well managed, high quality, relevant and appropriate care (Oxfam, 2007).
Sustaining Change
This program was conceived by the RCM identifying a gap in service provision for a patient group with identified inequality in health outcomes. Utilising pre-existing services (the DCAC for detection and Community nurses and Aboriginal Health Workers) has allowed for ongoing management and minimal cost. The NCAHS has committed to continuing the monthly DCAC and the Renal Service continues to allocate the RCM to this role.
A draft policy on the early management of CKD has been developed to facilitate the extension of this model across the other NCAHS networks.
The CKD NP is working closely with Aboriginal Health Workers to establish more CKD clinics.
Future Scope
The Area Renal Service is promoting a model of care that supports a CKD nurse in each Network. These staff will work with local health care providers for appropriate early referral and involvement in programs for Aboriginal and Torres Strait Islander people.
NSW Health has committed funds for prevention, detection and treatment of CKD in the Aboriginal and Torres Strait Islander population.
The RCM has presented the project at the National Renal Society of Australasia Conference in June 2008.
National health reform supports a change to a Primary health care approach, utilising Aboriginal Community Controlled Health Services.
References
- Cooper, J. et al. 2007. Partnership approach to Indigenous primary health care and diabetes: a case study from regional New South Wales. Australian Journal of Rural Health (15) pp67-70.
- Kneipp, E. 2004. Renal Disease in the Kimberley (Power Point presentation). Kimberley health regions. In partnership with the Kimberley Aboriginal Medical Services’ Council and the Kimberley Aboriginal Health Planning Forum. The First National Indigenous Dialysis and Transplant Symposium, June 2004.
- Manley, K. and McCormack, B. 2003. Practice Development: purpose, methodology, facilitation and methodology. Nursing in Critical Care (8)1. pp 22-29.
- McDonald, S., Chang, S. & Excell, L. 2007a. Key Summary Points. Australia and New Zealand Dialysis and Transplant Registry. The Thirtieth Report. Adelaide, South Australia. [Electronic version]. Retrieved online July 8th, 2008. http://www.anzdata.org.au/anzdata/AnzdataReport/30thReport/ContentsandSummary.pdf
- McDonald, S., Chang, S. & Excell, L. 2007b. Chapter 2. New Patients Commencing Treatment in 2006. Australia and New Zealand Dialysis and Transplant Registry. The Thirtieth Report. Adelaide, South Australia. [Electronic version]. Retrieved online July 8th, 2008. http://www.anzdata.org.au/anzdata/AnzdataReport/30thReport/Ch02NewPatients.pdf
- McDonald, S., Chang, S. & Excell, L. 2007b. Trends in Kidney Disease Over Time. Australia and New Zealand Dialysis and Transplant Registry. The Thirtieth Report. Adelaide, South Australia. [Electronic version]. Retrieved online July 8th, 2008. http://www.anzdata.org.au/v1/images/updates/Trends.pdf
- New South Wales Department of Health. 2002. Facts about Aboriginal Vascular Health. Better Health Centre Publications Warehouse.
- Oxfam Australia. 2007, April. Close the Gap! Solutions to the Indigenous Health Crisis Facing Australia. A Policy briefing paper from the national Aboriginal Community Controlled Health Organisation and Oxfam Australia. Oxfam Australia. Fitzroy, Victoria.
- Population Health Division (PHD). 2008. Aboriginal and Torres Strait Islander peoples. Diabetes hospitalisations. The health of the people of New South Wales - Report of the Chief Health Officer. Sydney. NSW Department of Health.
- Roger, S. 2005. Haematological targets. Iron. Caring for Australians with Renal Impairment (CARI) Guidelines. [Electronic version]. Retreived July 8, 2008. http://www.cari.org.au/DIALYSIS_bht_published/Iron.pdf
Contact
Manager, Clinical Governance Unit
North Coast Area Health Service
Phone: 02 6620 7225
This project was entered in the 2008 NSW Health Awards, Strengthen Primary Health and Continuing Care in the Community category.
