Telehealth – helping to ‘Close the Gap’ on Indigenous health.

How telehealth helps Aboriginal and Torres Strait Islander health

In early March 2020, six weeks after the novel coronavirus appeared in Australia, and two weeks before the Federal Government convened its new National Cabinet to tackle rising COVID-19 numbers, Australia’s Aboriginal and Torres Strait Islander health leaders were busy working behind the scenes.

They understood the catastrophic outcome if a viral pandemic swept through Indigenous communities: First Nations people have higher rates of underlying medical conditions; they are at greater risk of diabetes and renal failure; they have higher smoking rates; and they are more likely to live in crowded homes. Crucially, access to medical care in remote and very remote Indigenous communities can be problematic.

With the support of the Federal Government, what emerged from this Indigenous collaboration was the creation of the Aboriginal and Torres Strait Islander Advisory Group on COVID-19.

Referred to as the ‘Taskforce’, the group is co-chaired by the Department of Health and the National Aboriginal Community Controlled Health Organisation (NACCHO) – the peak body representing 143 Aboriginal Community Controlled Health Organisations (ACCHOs) across Australia.

The Taskforce includes leaders from NACCHO and its affiliates, Aboriginal Health Services, state and territory public-health representatives, the Australian Indigenous Doctors Association, and the National Indigenous Australians Agency (NIAA); it also includes Public Health Medical Officers (PHMOs) and communicable disease experts.

Responsible for overseeing its COVID-19 National Management Plan, the Taskforce has met at least weekly through the pandemic to ensure the delivery of Indigenous health care during the coronavirus pandemic is locally led, holistic, comprehensive, and culturally safe.

Telehealth – an important tool in the COVID-19 response

One of the Taskforce’s first actions was to start closing the borders of remote communities in early March 2020. Targeted messaging – often in Indigenous language – was quickly rolled out and GP respiratory clinics were set up within 23 ACCHOs to improve access to COVID-19 testing.

Increasing the delivery of health services by telehealth was also an important focus.

To date, Indigenous COVID-19 infection rates have been very low and there have been zero deaths.

According to NACCHO Medical Advisor, GP, and epidemiologist, Dr Jason Agostino, data from 2020 indicates a substantial proportion of services offered by ACCHOs was performed via telehealth. Telehealth was also responsible for increasing Indigenous access to GPs.

Dr Agostino anticipates this telehealth trend will continue to increase for all Indigenous Australians whether they live in urban or very remote locations.

“Essentially we’ve had an incredible natural experiment which is pretty unique, in that we’ve had such a rapid uptake of telehealth across Australia,” said Dr Agostino.

He says remote Indigenous health services usually rely on a permanent remote-area nurse or Aboriginal and Torres Strait Islander health practitioner on site, with GPs visiting a few days per week. Telehealth has the potential to improve both access to GPs, and continuity of care.

“What telehealth has the possibility of doing is strengthening the connection with our patient and improving continuity of care, which is where I think the difference is made,” said Dr Agostino.

“People rarely just need a doctor for a day; they need a doctor for their lifetime.

“If we have the ability to engage in some parts of care through telehealth – whether that’s following up results, or whether a patient who can’t come in because they’ve travelled somewhere else, still wants to touch base remotely – I think that’s an incredible thing if we can support continuity of care with a practice; with a team of GPs, nurses, and Aboriginal and Torres Strait Islander health workers and practitioners.”

Ensuring Indigenous telehealth services remain in place

Dr Agostino was part of a group of primary health care peak organisation representatives who worked with the Australian Government at the start of the pandemic when it was devising a list of temporary Medicare telehealth items.

The Medicare Benefit Scheme already has items that are specifically for ACCHO services and primary health care providers working in Indigenous health, and Dr Agostino says it was crucial that these items were also included on the list of Medicare telehealth items.

“We have a huge burden of chronic disease that starts earlier among Aboriginal and Torres Strait Islander people and we can’t simply leave those conditions unmanaged because people were concerned about coming into the clinic due to COVID-19,” explained Dr Agostino.

“…These specific [Medicare] items are really about chronic disease and follow-up with allied health, practice nurses, and Aboriginal and Torres Strait Islander health practitioners and there’s been good uptake of that throughout the pandemic and there continues to be use of those Aboriginal and Torres Strait Islander specific items.

“These items, and the general telehealth items have ensured that people have their normal care.”

Greater financial support for telehealth

One area requiring urgent industry review, says Dr Agostino, is the level of financial support for primary care nurses and health workers who use telehealth.

“One thing that is lacking at the moment is financial support for … what we call patient-end support: The person who is visiting may have hearing problems or English may be their third or fourth language, so they do often need help engaging in telehealth,” said Dr Agostino.

“What’s happening is they come into the clinic and the nurse or the health practitioner is still helping them while they’re seeing a remotely based GP or specialist, but all that work they’re doing at the patient end is unfunded at the moment which is a real gap in telehealth.”

He says that funding is also needed to improve internet connectivity across non-urban areas, as is access to technology in remote communities. NACCHO has been working with the National Broadband Network (NBN) on these issues, “but it’s a big area to work on”, says Dr Agostino.

“Ideally, we really want to be doing video consults ahead of tele consults because there’s a lot of things to be gained from video.

“Aboriginal and Torres Strait Islander, and non-Indigenous, we know that video accounted for only around ten percent of all the telehealth consultations that happened through the [2020] pandemic.”

Primary health care reforms

Another focus this year will be assessing the primary health care model used in ACCHOs.

Deputy CEO of NACCHO, Dr Dawn Casey, is on the Federal Government’s Primary Health Reform Steering Group which is advising government on a ten-year plan to improve the delivery of primary care in Australia.

Dr Agostino says the ACCHO model is effective and unique in that its services provide both public health and primary health care in the one spot.

Under the model, each ACCHO is run by a board of local Aboriginal and Torres Strait Islander people to deliver public-health functions by directly employing staff to provide services such as quit-smoking programs, healthy lifestyle programs, prevention of sexually transmitted infections, and other important community programs.

In the same place, comprehensive primary health care is also provided by ACCHO medical staff to patients with complex care needs.

“We are bringing care into one place and doing it under the guidance of the community-controlled board,” said Dr Agostino.

“It is an effective model of care and we want to continue to strengthen that to make sure that it is sustainably funded.”

COVID-19 response – a success story for Indigenous communities

COVID-19, says Dr Agostino, created a challenging 2020 for Indigenous Australians. There were early reports that Indigenous people were being discriminated against and turned away inappropriately from public testing centres. The pandemic placed stress on the supply of fly-in-fly-out doctors to remote ACCHO locations, and it decreased ACCHO revenue (particularly during April and May) when lockdown orders frightened people away from medical services.

“But overall,” said Dr Agostino, “the outcome has been really positive for Aboriginal and Torres Strait Islander people, in that the COVID-19 response been a real success story.

“It really shows what can happen when governments listen to Aboriginal and Torres Strait Islander people and they let [Indigenous] communities get on with the good work they know how to do for the health of their community.”

Indigenous health professionals practicing for a remote outbreak response

Dr Agostino, who is based in Canberra, also works as a doctor at an ACCHO in Far North Queensland called Gurriny Yealamucka, which means ‘healing water’. He believes that fostering community empowerment and leadership is the way of the future for Aboriginal and Torres Strait Islander people.

Importantly, this approach synchronises with the reforms outlined in the Closing the Gap agreement on reducing Indigenous inequality, that was released by the Federal Government in June 2020.

“Really, that’s what we’re focused on,” said Dr Agostino when considering the new year ahead.

“Emphasising these reforms which are around shared decision making between Aboriginal and Torres Strait Islander people and the government; investing in community control because we know communities are the best place to deliver services to Aboriginal and Torres Strait Islander people; working with government organisations to do business better; and also having really good access to data to inform decision making at the local level.

“So that’s what our focus is: to continue working to those national reforms in all areas of government, and in all of our [NACCHO] areas.”