by Scott Monaghan, Andrew Black, Marion Tait, Hannah Visser
Bulgarr Ngaru Medical Aboriginal Corporation (BNMAC) was established in 1991 to provide health services to the Aboriginal communities of the Clarence Valley, and now operates a regional network of comprehensive primary health care services covering the traditional clans of the Yaegl and Gumbaynggirr Nations and a large proportion of the Bundjalung footprint.
BNMAC provides services to communities from Tweed Heads to Grafton, including Grafton, Baryulgil, Malabugilmah, Yamba, Maclean, Casino, Box Ridge, Muli Muli, Tabulam, Kyogle, Tweed Heads South, Chinderah, Fingal Heads and Banora.
The emergence of the global pandemic necessitated BNMAC, like society at large, to respond to unprecedented circumstances. The extensive media coverage, the incessant social media postings, even conspiracy theories, heightened the confusion and anxiety felt by many in the Aboriginal community. The economic situation of disadvantaged communities added to this anxiety.
From the start we knew that access to reliable and timely information about the virus was important. Soon BNMAC took on the role of trusted information broker in regard to the virus. Facebook proved a viable platform for disseminating accurate information to the community. This was supplemented by BNMAC health workers communicating important information through their networks.
In developing a response to the new circumstances, social and cultural matters relating to the Aboriginal community were thought through carefully and consulted upon with the community and the Aboriginal staff at BNMAC. We recognized that the Elders had to be protected, given their custodianship of community knowledge and their role in Aboriginal community life.
They bring much-needed resilience to the community. The multigenerational nature of Aboriginal communities introduced an important consideration. The children in Aboriginal communities move freely and are cared for by the older folk and enjoy a closeness to them. This presented a potential risk, as the children could become unwitting vectors for the spread. Also, living arrangements in the Aboriginal community often accommodate many in the same household, making quarantine or self-isolation harder.
The mobility of the Aboriginal population was another important consideration. We thought small in-land isolated towns such as Tabulam provided a layer of protection; little did we think that family members in large cities during lock down may seek to escape the loneliness and restrictions imposed on them. They came to enjoy the freedom that these small settlements offered. Coastal towns such as Yamba that have a substantial Aboriginal population, though isolated, are surrounded by wealthy, retired non-Aboriginal populations that undertake travel and cruises, which could unintentionally expose the Aboriginal community to health risks.
In BNMAC, like other services, we were initially unsure how to prepare our response to this health crisis, and the community was uncertain how to protect itself. Our existing plans and procedures were not adequate for responding to a pandemic of this nature. We had to act quickly, adapt, and develop an appropriate response. We updated our flu pandemic plan, modified the infection control procedures, and adjusted care delivery.
After a review, to minimize and mitigate the risks of exposure for the workforce as well as the community, the number of locations from which clinics were offered was reduced. We developed a workforce strategy and stratified staff by personal health risks and took steps to protect them. This guided the arrangements for BNMAC staff who worked from home and those who continued to work from the clinics.
The clinic waiting rooms were rearranged to ensure patient physical distancing, with clearly marked patient and clinician zones. We exercised many site drills and simulations involving the entire workforce in the clinic – starting with the receptionists and the important role they played in ensuring safety and management of sick patients with potential COVID-19 exposure and communicating with patients unable to quickly understand the instructions.
A process was established early on to stratify and prioritize the care of patients with highest risks. Those aged 40 and over with more than one chronic ailment were categorized and each patient’s health profile closely examined. The most vulnerable were listed. Our clinicians were also given the opportunity to add other patients to the list, at whatever age, that they considered susceptible.
Weekly or fortnightly contact was made with these at-risk patients by a nurse or Aboriginal health worker to carry out a ‘well-being check’. Through the conversations it was determined whether GP consults were needed, either face-to-face or by telephone. This ensured the patients received holistic and team-based care. In addition to this list of patients, other individuals, particularly at-risk young men not seen for some time, were identified by our Aboriginal health workers and contacted.
This period proved that telephone consults are an effective option for delivering GP primary care. The introduction of telephone consultation was carried out carefully and with due consideration of the circumstances of the Aboriginal community. The video consultation option was discounted since many in the community do not have the required phone data. At the outset an 1800 free call number was established. The patients were often offered a phone consult with the GP and then it was determined whether a face-to-face consult was necessary.
While face-to-face is still the best option for care, this intense period proved telephone consults to be an excellent addition to the service options available to the community. Telephone consultations facilitated swift communication with patients and provided the capacity to respond in a timely manner and with greater agility; both in creating care plans and in providing care.
The community members have appreciated having this health care option and most have embraced it. Telehealth has improved health care access for patients, eliminated transportation barriers, and facilitated quick communication between practitioners and patients. This consult option also meant that patients who might miss appointments did not need to wait for another week or so to see the doctor. The number of no-shows was reduced.
Furthermore, GPs have noted that clients spoke more readily and freely on the phone; some clients who usually said little in face-to-face consults spoke at length. There was also an upside for some mental health patients. Those with severe anxiety were comfortable to receive care at home.
Another important learning was related to diagnostic test result. The average time for test results to be communicated to patients is about three weeks, unless prioritized. During this period, given that the patient consult was on the telephone, the time was reduced significantly to just a few days. Additionally, the process set up for specialist consults for patients by phone worked very well, and notably the specialist response, and the receiving of patient notes and letters, were faster than usual.
A few fever clinics were initially established in major local hospitals. Vulnerable patients in outlying areas with limited transport found it difficult to access these clinics and chose to go to Aboriginal Medical Services for their care. The eventual establishment of fever clinics by BNMAC in collaboration with the Local Health Districts (LHD) proved an effective model.
Adversity and challenging times bring opportunities for change and advancement. During this difficult period, we witnessed a significantly increased openness to change. Clinicians and communities were receptive to changes that otherwise they might have been reluctant to consider. During this time, we were able to introduce and establish innovations under consideration for some time.
For example, we developed partnerships and established joint integrated clinics that previously would have taken months, even years. We changed care delivery models with agility and effectiveness. And importantly, this period of change has given the community confidence and courage to do things differently. We are determined to sustain these improvements.
It is in periods of significant change that strong leadership, trust, and goodwill at the community, clinician, and management levels are needed. We have seen this in abundance. We want to systematically document our experience and the knowledge gained, reflect on these, and use them to make sustained changes.
Mr Scott Monaghan is the Chief Executive of BNMAC; Dr(s) Black, Tait and Visser are General Practitioners at BNMAC.