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There was no funding for this program and funding that was applied for was unsuccessful. As we felt the need for a comprehensive respiratory program was high we joined forces with the Health bodies around - North Coast Area Health, Richmond Clinic (Drug and Alcohol), and Casino Community Health - to plan and implement a program that is now up and running.

Our staff have been mentored and trained by a Physiotherapist and Asthma educator from Casino Community Health. Through this our staff are now confident to run a respiratory clinic independently and have done very successfully. The communities are extremely happy for this service and we are now in demand.

This program has been bought to the notice of the Australian Lung Foundation who have decided to train our staff in Pulmonary rehabilitation as a pilot. This is at no cost to ourselves and will further enhance our abilities to continue to run this program.

As all resources have been sourced locally and the teams put together have given their services at no cost to ourselves, and in doing so have up skilled the Dharah Gibij staff and not just one person, we feel this program meets the criteria for an enterprising program with wide reaching, effective and sustainable outcomes.

The smoking cessation component of "Bugl Booyay" has again been developed through Health promotions, Richmond Clinic, North Coast Area Health, Population Health and Dharah Gibinj, and a set of reproducible and trainer friendly resources have been developed and documented for the ongoing use of all aboriginal health workers. A large proportion of Aboriginal Workers and Clinical staff have been trained already and a training package has been developed and is being evaluated to provide an on going resource. All staff that have attended the training are now confident to tackle the issue of smoking in our communities.

Dharah Gibinj Aboriginal Medical Service, undertook a review of the prevalence of chronic disease within their patient register in 2008. This revealed that chronic respiratory disease, predominantly Asthma, was the most prevalent with 294 patients compared to heart disease 172, diabetes 206 and renal 78.

At this time there were no respiratory disease focused services provided from Dharah Gibinj Casino.

"Chronic respiratory disease hospital separation rate is 4-5 times that of non Aboriginal people." - The NCAHS Aboriginal Health and Wellbeing Strategic Plan 2008

Population Health Northern Rivers had previously collated data on premature deaths from Respiratory Disease on people under 75 years of age. Casino was very much in need of intervention. This data and the numbers of Respiratory patients we were able to identify on our patient base being the greater chronic disease burden in our community became the motivation behind "Bugl Booyay". As this was a new concept for this AMS there was no funding set aside to develop or implement this program.and there were no examples to base our program on.

We used these resources as the best practice guidelines for setting up our program:

• Chronic Disease Guidelines, 2nd edition, QLD Health
• Aboriginal Primary Health Care: an evidence based approach, 3rd edition, Sophia Couzos and Richard Murray

We also used the expertise of NCAH and Casino Community Health in planning and implementing "Bugl Booyay" - Good Breathing.

• To increase awareness of lung disease in the local Aboriginal population.
• To prevent smoking related chronic respiratory disease.
• To improve health outcomes for Aboriginal people with respiratory disease.

• To develop a suite of evidence based respiratory disease services which targeted both prevention and disease management.
• To up-skill the clinical workforce at Dharah Gibinj in smoking cessation, respiratory assessment and respiratory disease management.
• Optimise access to the respiratory services by delivering to local communities in the most culturally appropriate way.

Consultation occurred with the local Aboriginal community regarding lung problems and what needed to be done. The community identified they needed help for their people to stop smoking, better understanding of lung problems and more help for people already suffering with lung disease

A review of current service for chronic respiratory disease at Dharah Gibinj identified:

• Service provision was focused on medical management of acute respiratory exacerbations presentations.
• Spirometry was not routinely utilised to assess lung function and it was suspected that Chronic Obstructive Pulmonary Disease (COPD) was under diagnosed and managed in the population.
• The high current smoking rate was contributing to the prevalence and severity of respiratory disease in local community.
• Referral and attendance at outreach clinics by a visiting respiratory physician were under utilised.
• No smoking cessation program/ process available to support increasing numbers of patients wanting assistance to quit smoking.
• Aboriginal people with moderate to severe respiratory disease did not access mainstream respiratory education or pulmonary rehabilitation program currently available through the local hospital.

A partnership was formed with the North Coast Area Health Service (NCAHS) respiratory coordinator to provide clinical support in the development of respiratory services and providing up-skilling for their clinical workforce.

Research was undertaken to identify existing culturally appropriate resources and Aboriginal respiratory programs that could be adapted for use at Dharah Gibinj.

Four core respiratory service components were prioritised:

• Lung Health and disease awareness
• Respiratory assessment clinics
• Smoking cessation support
• Pulmonary rehabilitation

The visiting respiratory physician sessions were combined with the existing and well supported "Men's Healthy Food" program which rotated to outlying communities. The initial focus was for the respiratory physician to increase community awareness of lung health, lung disease and the associated impact of smoking. An innovative approach was taken to engage interest with men in the communities by using fresh pigs lungs at each lung health session (obtained from local abattoir) and then offering to share a sandwich made with poisonous substances in a cigarette.

A Lung Friendly House laminated flip chart resource was used to show the community about avoidable respiratory triggers within the home including dust mites, mould, sneezing and coughing hygiene and exposure to tobacco smoke.

A Respiratory assessment including spirometry and follow up at Dharah Gibinj was offered following the lung health session.

A monthly respiratory multidisciplinary clinic was developed and commenced at Dharah Gibinj in Oct 2008. The team consisted of the respiratory physician, Dharah Gibinj nurse, Aboriginal Health worker, exercise physiologist and a physiotherapist/asthma educator provided from Casino hospital (4 hours per month) to support the Dharah Gibinj staff initially in the respiratory clinic. The physiotherapist/asthma educator aimed to work with Dharah Gibinj staff to provide 'on the job' up-skilling in respiratory assessment, disease education, medication use and device technique skills.

Each patient is assessed by respiratory physician, does a 6 Minute Walk test assessment of exercise capacity (exercise physiologist), spirometry (nurse), disease, medication education and review of respiratory device techniques (Aboriginal Health Worker).

A case conference including all staff and Dharah Gibinj GP is conducted at the end of each clinic. Patients are re scheduled for planned review with GP or respiratory specialist as appropriate.

The respiratory physician was added to the appointment book in practice software system to enable GP's to refer patients directly into the following monthly clinics.

In April 2009, the confident and experienced Dharah Gibinj respiratory team commenced providing outreach multidisciplinary respiratory clinics, without the supporting physiotherapist, in rotating outlying communities.

A 2008 submission for external funding to support smoking cessation training for all Dharah Gibinj staff was unsuccessful. Whilst the majority of Dharah Gibinj staff had participated in Smoke Check training, staff felt they lacked knowledge and skills in supporting individual people to quit smoking.

The respiratory coordinator negotiated with NCAHS Health Promotion and Drug and Alcohol staff, who were highly skilled in cessation, to work with Dharah Gibinj Respiratory Team to develop a culturally appropriate smoking cessation training program for their staff.

A 2 tiered smoking cessation training program was developed based on current evidence for successful smoking cessation support. Level 1 was aimed at basic knowledge and practical skills for all health workers with an optional level 2 for health workers who wanted more in depth understanding of the physiology, medications and motivational interviewing. A standardised set of laminated flip chart resources were created to ensure consistent and accurate information and advice was provided by all staff.

A smoking cessation group program is now in development and planned to be run in partnership with NCAHS cessation staff initially from mid 2009.

Patients motivated to quit are being identified from the respiratory clinic and will be targeted for the first cessation group.

Whilst suitable Aboriginal inpatients are identified in hospital and pulmonary rehabilitation services are available through the local hospital, there has only been 1 Aboriginal person commence but not complete the rehab program since 2003.

A pulmonary rehabilitation service on site at Dharah Gibinj was proposed as a solution to the existing barriers for Aboriginal people accessing mainstream services. NCAHS agreed to support the development of a pulmonary rehab program at Dharah Gibinj and 'on the job' training for their staff.

The Australian Lung Foundation had developed a  set of training and pulmonary rehab program resources for Aboriginal and rural and remote communities called Breathe Easy, Walk Easy. The leadership and commitment for improving respiratory disease management at Dharah Gibinj and the strong partnership with NCAHS respiratory services has resulted in Dharah Gibinj being selected to be the  pilot site for the evaluation of  the Breathe Easy, Walk Easy training resources in May 2009.

A pulmonary rehab program is planned to commence in June 09 at Dharah Gibinj in partnership with NCAHS respiratory services. Funding has been secured to purchase  a pulse oximeter, exercise bike and CO monitor to support the program.

Patients suitable for pulmonary rehab are being identified at the respiratory clinics and will be targeted for the first North Coast Aboriginal pulmonary rehab program to be conducted at Dharah Gibinj.

Combining the respiratory physician with the "Mens Healthy Food" program has increased the number of Aboriginal people receiving respiratory assessments in the outlying communities.

April- Sept 08 Respiratory Physician clinic assessment (5 month period ) = 20
Nov - April 09 Respiratory Physician assessment (5 month period) = 193

Dharah Gibinj, Oct 08 - April 09

• Patients assessed = 38
• Patients referred for further investigations = 11
• Planned medical review = 18
• Spontaneous walk ins for respiratory check up=155

Outreach, April 09

• Outreach respiratory clinic = 5 + more clinics scheduled in May 09

There were 30 staff from Dharah Gibinj and local community health service who attended the inter professional Level 1 Cessation training. Of these, 19 staff including the respiratory physician then completed level 2 Cessation training.

Following the training there has been multiple enquiries from staff in the area for a possible repeat of the training. There are currently 15 on a course waiting list.

There are 14 people who have indicated that they would like to attend the Quit Smoking group program commencing in June 09.

After assessing and our program this far the Lung Foundation has chosen this AMS to become the pilot AMS for the training package they have produced. They were impressed at what we had implemented and that the program was sustainable and felt that they could invest their time and expertise into our AMS. This was a very proud moment.

The Breathe Easy, Walk Easy training 1 day pulmonary rehab training for Dharah Gibinj staff ran in May 2009. This pilot of the training resources is being formally evaluated by the Australian Lung Foundation and Sydney University.

Evaluation will include changes in knowledge, attitudes and service delivery at completion of the training and 1 month post training .The outcomes from the evaluation will be used to inform a planned roll out of the Breathe Easy, Walk Easy resources nationally.

There are currently 7 Aboriginal people who have agreed to attend pulmonary rehab which is scheduled to commence in June 09.

The impact of respiratory disease on the local Aboriginal population has been recognised.

The local health providers, Dharah Gibinj and NCAHS have collaborated to develop a suite of services that address the respiratory needs of their Aboriginal community. There has been no requirement for grants or additional funding as the respiratory services have been provided within existing resources and the training and building of clinical skills has occurred on site. Ongoing strong clinical partnerships have been established between Dharah Gibinj and NCAHS Respiratory and Health Promotion services.

There has been a significant increase in the number of Aboriginal people from this area of the North Coast who receive evidence based respiratory screening, assessment and referral to local culturally appropriate smoking cessation and respiratory disease management programs. There is now an opportunity to disseminate these respiratory service improvements to other sites within the North Coast, and improve respiratory health outcomes for our Aboriginal people.

Dharah Gibinj Aboriginal Medical Service
Phone: 02 6662 3514