Can community-level strategies improve timely diagnosis of chronic conditions and best-practice care for older Aboriginal and Torres Strait Islander people including dementia?

A cluster randomised controlled trial with 16 eligible communities randomised to either (i) a community based multi-component intervention (n=8); or (ii) usual care (n=8). Interventions: Aboriginal Community Controlled Health Services (ACCHSs) allocated to the intervention condition will receive a 3-year multi-component community-based intervention designed to address barriers to the timely diagnosis of dementia and the provision of best practice care. Intervention components are based on an extensive review of the literature and recommendations of multidisciplinary experts, and will be further refined by the Aboriginal Advisory Group and through a local community consultation and engagement process. Timing of the implementation of each strategy will be determined in consultation with each individual ACCHS. The intervention will be implemented in Years 2-4. Further strategy development, consultation and baseline data collection will occur in the first 12 months (Year 1). A 3-year community-based intervention will commence in Year 2 and will completed at the end of Year 4. 1. Community-level strategies a) Community information sessions to raise dementia knowledge. Each ACCHS will be supported to hold a series of 1-hour community dementia knowledge sessions in Years 2, 3 and 4 (one session annually). A trained ACCHS staff member will be supported by the research team to deliver the session. b) Supportive Care Community Networks The community consultation processes will identify agencies that could form a Supportive Care Network. Likely representation will include those from ACCHSs, hospitals, aged care services, allied healthcare, legal services and Aboriginal people living with chronic disease, their carers and families. Where required ACCHS representatives who facilitate the meetings (4 meetings/year) will be offered facilitation training and consumers will be offered advocacy training. The remit of the Supportive Care Network will be determined in consultation with each Aboriginal Medical Service (AMS) and will reflect the local community needs. Prior to further consultation, it is envisaged that the Supportive Care Network's role will be to ensure coordination of care for older Aboriginal people. This is likely to result in improved communication between community-based organisations and ACCHSs. The Support Care Networks will map and identify gaps in existing referral pathways and communication processes, and problem solve in regards to care for people living with dementia and their carers and families. c) The development of culturally appropriate and locally tailored information resources. The community consultation will allow for the identification of knowledge gaps, and local, state and not-for-profit resources (e.g. brochures, websites, apps, online forums) which will be of benefit for the community information sessions and the Supportive Care Networks. Resources will be developed and may include information regarding ageing and the common signs of cognitive impairment, depression, anxiety, diabetes, hypertension, high cholesterol, coronary heart disease (CHD), stroke, COPD, cancer (all types) and kidney disease. 2. Strategies supporting ACCHSs to identify persons with chronic disease & deliver best practice care. a) GP, Practice Nurse, Aboriginal Health Worker training During the consultation process, we will invite ACCHS staff to attend a 2-hr meeting, to ascertain educational needs regarding chronic disease, dementia diagnosis and care. Consultation will be conducted in small groups or as one-on-one interviews, via telephone or Zoom. The consultation process will occur during the initial 12-month baseline period, prior to implementation of the community support strategies. Relevant ACCHS staff including GPs, practice nurses and Aboriginal Health workers will receive 1-2 days training in conducting MBS715 health assessments using the tailored 715 template. Training will also cover appropriate management steps for diabetes, anxiety, dementia, depression, hypertension and high cholesterol. Given staff turnover at ACCHSs, refresher training will be repeated each year throughout the C-RCT period to consolidate knowledge and ensure any new staff receive training. Training will be conducted face-to-face or via videoconference by 1) a GP and Aboriginal Health Worker and 2) Communicare support trainer. Training will cover RACGP/NACCHO guidelines in relation to MBS715 health assessments; practical issues for administering these with patients; and the layout and technical features of the MBS715 template. ACCHSs will be reimbursed for the nurse and Aboriginal Health Worker staff time required to complete the training. b) Embedding cognitive assessment into MBS 715 Health Assessments. Step one: Each month, an ACCHS staff member will run a tailored PenCAT report to identify active patients aged over 45 years who have not completed a MBS 715 Health Assessment in the previous 12 months. These patients will be triaged based on pre-existing conditions associated with dementia (e.g. diabetes, heart disease) and dementia lifestyle risk factors (e.g. smoking, alcohol misuse). The staff member will contact identified patients and schedule a time for them and their families to come to the clinic and undertake the Assessment. Step two: An electronic template will be developed and tailored for use by each ACCHS. It will prompt staff to cover relevant items in the MBS 715 screen, including asking the patient and their family members if they have any concerns about the patient’s cognitive functioning. If this is reported, the template will prompt the ACCHS staff member to assess cognitive ability using the Standardised Mini Mental State Examination (SMMSE). The MBS715 Health Assessment can take up to one hour to complete. Step three: GPs will review the completed health assessment. The GP will undertake further assessment of patients who have scored under 24 on the SMMSE regarding potential causes of suggested cognitive impairment. If a patient is diagnosed with dementia, a Care Management Plan will be developed. c) Electronic templates in Medical Director/Communicare for: (i) Referral to My Aged Care. To overcome barriers such as lack of time and knowledge of services available and how to access them, an electronic template will be developed for GPs using their usual medical practice software. The template will include the initial assessment questions asked by My Aged Care staff that determines if the patient will progress to a formal assessment by the Regional Support Services (RAS) or the Aged Care Assessment Team (ACAT). The Case Manager will log the referral on the My Aged Care website to commence the assessment process. (ii) Dementia management care plan. In line with best care, the GP will develop a dementia management care plan in partnership with each person diagnosed with dementia and their family. The template will include comorbidities, management goals, actions for patient/carers, treatment/referral options, and arrangements to review the plan. d) Bi-monthly feedback regarding performance. In collaboration with the Aboriginal Advisory Group, a system change feedback template will be developed and will provide data to each ACCHS regarding: (i) the number and proportion of active patients aged over 45 years who attended the ACCHS in the previous month and had a completed Health Assessment. From this data, the MBS rebate dollar amount received and the potential MBS dollar amount missed will be calculated; and (ii) the number of new confirmed diagnoses of chronic conditions, including dementia recorded in the medical record. ACCHS bi-monthly performance against set targets for the ACCHS will be displayed using text and graphics, and new targets for the next month will be discussed. ACCHSs will be reimbursed for staff time to complete the reports. 3. Strategies to directly support older adults and their families: A 0.5 FTE Older Persons Care Coordinator, will be appointed at each ACCHS. The Case Manager will act as an advocate and support for older people who have completed an MBS715 health assessment and their families. The role of the care coordinator would be negotiated with the ACCHS. Based on the results of the 715 assessment, the Coordinator will collaborate with the GP, ACCHS staff, and local Aged Care and other services to help ensure access to, and the coordinated delivery of, health and appropriate aged care and other support services.