"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

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

Implementation and Evaluation of an Aboriginal Transfer of Care (ATOC) Model: Final Report

Transfer of care initiatives aim to improve transfer of care for patients to and from acute settings and back to primary care, i.e. GP and community. Aboriginal people with chronic conditions are more likely to leave hospital with incomplete transfer of care arrangements and to be readmitted after a recent hospitalisation. The South Western Sydney Local Health District (SWSLHD) Aboriginal Transfer of Care (ATOC) model extends traditional discharge planning to provide structured transfer of care for Aboriginal patients. A pilot of the ATOC model in Campbelltown Hospital decreased unplanned readmissions for Aboriginal patients with from 15.6% in January 2016 to 5.7% in April 2016. Following these promising findings, ATOC was also adopted at Liverpool Hospital