Quantitative evaluation of an outreach case management model of care for urban Aboriginal and Torres Strait Islander adults living with complex chronic disease: a longitudinal study

Abstract

Background Chronic diseases are the leading contributor to the excess morbidity and mortality burden experienced by Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) people, compared to their non-Indigenous counterparts. The Home-based Outreach case Management of chronic disease Exploratory (HOME) Study provided person-centred, multidisciplinary care for Indigenous people with chronic disease. This model of care, aligned to Indigenous peoples’ conceptions of health and wellbeing, was integrated within an urban Indigenous primary health care service. We aimed to determine the impact of this model of care on participants’ health and wellbeing at 12 months. Methods HOME Study participants were Indigenous, regular patients of the primary health care service, with a diagnosis of at least one chronic disease, and complex health and social care needs. Data were collected directly from participants and from their medical records at baseline, and 3, 6 and 12 months thereafter. Variables included self-rated health status, depression, utilisation of health services, and key clinical outcomes. Participants’ baseline characteristics were described using frequencies and percentages. Generalized estimating equation (GEE) models were employed to evaluate participant attrition and changes in outcome measures over time. Results 60 participants were enrolled into the study and 37 (62%) completed the 12-month assessment. After receiving outreach case management for 12 months, 73% of participants had good, very good or excellent self-rated health status compared with 33% at baseline (p < 0.001) and 19% of participants had depression compared with 44% at baseline (p = 0.03). Significant increases in appointments with allied health professionals (p < 0.001) and medical specialists other than general practitioners (p = 0.001) were observed at 12-months compared with baseline rates. Mean systolic blood pressure decreased over time (p = 0.02), but there were no significant changes in mean HbA1c, body mass index, or diastolic blood pressure. Conclusions The HOME Study model of care was predicated on a holistic conception of health and aimed to address participants’ health and social care needs. The positive changes in self-rated health and rates of depression evinced that this aim was met, and that participants received the necessary care to support and improve their health and wellbeing.

People with Multiple Long-Term Health Problems: Personalized Care Planning

“…The nurse should also encourage and empower people to be active participants in their health and with the teams for the co-construction of the collaborative care plan centered on the person, with the definition of their objectives, goals, priorities, and purpose of their health and well-being [9,24], and should promote negotiation [8,11]. The nurse is expected to strengthen the person's motivation and commitment to behavior change, which involves partnership, acceptance, compassion, and evo-cation, shaping the conversation with the person to evoke and commit the person to behavior change [27] through motivational interviewing [10,14].…”

“…Case management is centered on people with longterm health problems in the community, with an emphasis on education, self-management, and collaboration, so that people can manage their health condition [20] the responsibility is shared between nurse and person to improve outcomes for health conditions such as diabetes and hypertension [22]. This practice is based on centered, individualized, personalized partnership between the nurse and the person with multiple long-term health problems [8,9,23], with the support of multidisciplinary nurse-led community teams [7,24].…”

The cultural safety of reports of research on primary healthcare use by Indigenous Peoples: a systematic review

“…Many of the papers (80%, 28/35) reported honouring Indigenous ethical guidelines and obtaining ethical approvals from relevant Indigenous ethics committees with only 20% (8/35) papers lacking the detail of this. (21,22,28,(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41) However, these eight papers did include ethical approval but from non-Indigenous organisations.…”

Support along the cancer pathway for Aboriginal People

“…Home-based outreach case management of chronic disease exploratory (HOME) study 142,143 A home-based case management model of patient-centred multidisciplinary care for Aboriginal and Torres Strait Islander people with complex CD that was integrated into a primary healthcare service. The HOME study model of care had two distinct phases.…”