Holistic, sustainable secondary prevention for chronic disease

Recent research undertaken in rural and remote areas of North Queensland proposes that provision of secondary prevention in these areas could be improved through health system changes. These include referrals to community nurses and Aboriginal and Torres Strait Islander Health Professionals (ATSIHP); increased coordination, communication and collaboration; and multidisciplinary health care based on hospital discharge plans that include risk management. To be successful, revised systems require in-service education, policies and guidelines, together with improved communication, coordination and collaboration between healthcare professionals and organisations.

The research included extensive consultation and data collection from healthcare staff and community members, to investigate support for people discharged from hospital following treatment for heart disease. Findings indicated that rural and remote areas rarely received holistic post-discharge secondary prevention in their home community, despite nurses or ATSIHP being available.

Nurses and ATSIHP in rural and remote areas were supported by resident or visiting allied health professionals (AHP) and medical staff, who delivered face-to-face, telehealth or telephone services. However, there were low levels of holistic care and secondary prevention, plus low coordination, communication and collaboration between health service providers and organisations. Overall, healthcare systems were weak.

Nurses reported that they felt confident with providing clinical care but lacked confidence in chronic disease risk factor management. AHP expressed frustration at predominantly receiving referrals for people with joint problems and surgery or back and neck pain, rather than for holistic secondary prevention, which is part of their role. ATSIHP frequently reported being under-utilised and disempowered.

No standardised system for chronic disease secondary prevention was found. However, the diabetes education and self-management program provides an example of an effective secondary prevention program. This program is led by nurses or AHP who have received specialist training – diabetes educators (DE). The DE role includes disease management, education and coordination of multidisciplinary care that includes AHP and medical officers who provide holistic, multidisciplinary risk factor management.

Overall, research findings indicated that AHP and ATSIHP are generally not utilised to their full scope of practice in rural and remote areas. ATSIHP who live and work in their local community, and speak the local language, were commonly not supported to provide holistic, culturally appropriate care. Nurses were limited in their ability to provide holistic care due to delay or absence of hospital discharge referrals and discharge plans, and lack of confidence to provide risk factor management.

Western medical care continues to be predominant in healthcare delivery. This approach lacks flexible, client-centred, multidisciplinary care and contributes to people not attending appointments, disempowerment and cultural barriers. Aboriginal Community Controlled Health Organisations provide an example of holistic, flexible, culturally responsive care that could be utilised effectively.

To build on strengths and address weaknesses, it is proposed that healthcare systems are revised. Identified changes include the development and implementation of:

1. hospital discharge plans that include recommendations for risk factor management and AHP referral, sent to community nurses or ATSIHP in the client’s local community
2. guidelines and procedures for management and coordination of holistic post-discharge health care, including risk factor management and client education, leading to self-management
3. in-service education for nurses and ATSIHP on chronic disease secondary prevention and risk factor management
4. case management meetings and sharing of healthcare information between the multidisciplinary team involved in the client’s care.

Through systems change, revised policies, guidelines and education, it is proposed that flexible, holistic health care could be provided in rural and remote areas by community nurses, nurse practitioners and ATSIHP who coordinate a multidisciplinary team approach to provide culturally responsive secondary prevention for people in their local community with chronic disease. Such a model could result in improved health care and outcomes, reduced hospitalisations, improved staff satisfaction and potentially reduced staff turnover – and needs to be trialled.