IUIH CONNECT. Connecting Health Services, together for Aboriginal and Torres Strait Islander People. Free Call
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1 IUIH CONNECT Connecting Health Services, together for Aboriginal and Torres Strait Islander People Free Call
2 WHO ARE WE The Institute for Urban Indigenous Health (IUIH) was established in July 2009 as a strategic response to the significant growth and geographic dispersion of Aboriginal and Torres Strait Islander peoples within the South East Queensland Region. IUIH oversee: Moreton ATSICHS comprehensive primary health care clinics. IUIH Home Support for people over 50 s IUIH Regional Transport ITC Closing the Gap and CCSS program Social Health Programs Family Well Being Program for vulnerable families ANFPP for mums and bubs DEADLY CHOICES preventative health and education MomenTIM Tomorrow s Indigenous Men
3 IUIH and partners
4 AMS SERVICES Preventive health checks 715 (every 9 months) GPMP & TCA - Chronic disease screening, management, and ongoing care CCSS - Care coordination for clients with chronic disease care needs Mums and bubs services including antenatal care for pregnant women and their families, post-natal care in the clinic or home, and early childhood screening and development services Mums & Bubs, ANFPP Social health services including community-based mental health and alcohol and other drug services ICRS, PiR, Family Well Being Program Tele-health services Dental and oral health services through the clinics Allied Health services: Optometry, audiology, podiatry, physiotherapy, occupational therapy, speech therapy for children, Work It Out Program.
5 BACK GROUND MNHHS and IUIH established a partnership which assisted Aboriginal and Torres Strait Islander People at risk of chronic diseases to access culturally appropriate health care services. Given the changing landscape within Queensland Health and the corresponding increase in the reach of IUIH services across SEQ, an agreement was reached for IUIH to deliver what is known as IUIH Connect. IUIH Connect will provide a comprehensive care coordination service to facilitate effective and culturally appropriate transfer of care arrangements.
6 WHAT WE PROVIDE The IUIH Connect Program is funded through QH and is for the delivery of care coordination and with the intention to assist patients in the seamless transfer of care provision between community and hospital and hospital and community. IUIH Connect will assist the patient, patient s family and the referring GP to ensure transition into Hospital is a smooth one.
7 IUIH Connect IUIH Connect improves the quality of health care for Aboriginal and Torres Islander People by bringing together different health services towards a common purpose. Funding to assist clients to access medical aids and services Referral Process working with the ATSIHU, discharge planners, allied health. QPS referrals for SEQ & Moreton Bay area
8 IUIH Connect Service Model of Care IUIH Connect follows an integrated model of care built upon the following principles: Building Trusting Relationships with Clients through hospital visits, telephone contact and home visits. Giving consideration to the cultural need of client. Linking between Tertiary and Primary Care liaising with other service providers and forming the bridge from tertiary to primary healthcare Developing Holistic Transition Plans for Clients and their Families assessing needs, planning for discharge, home visits, case conferencing and advocacy Investing in Relationships with Service Providers developing new pathways, maintaining existing pathways and educating service providers about the program Handing Over to other Service Providers working with any service provider, not just services associated with IUIH but with other external agencies. Following-up with Clients recognising follow-up as an essential part of care
9 IUIH Connect Referrals received between (QPS referrals commenced in 2016) July-Dec 2014 Jan-June 2015 July-Dec 2015 Jan-June 2016 July-Dec 2016
10 Referrals received per facility July December % 2% 1% 3% 6% 15% 6% 11% 3% 3% 0% RBWH TPCH RED CAB PA QPS MATSICHS IUIH Other QH facil SELF 49% Ngarrama OTHERS
11 Axis Title Referrals received by age bracket July-Dec Unknown Series2 Series Unknown Series Series2 3.70% 14.60% 20.00% 13.20% 16.10% 24.70% 7.70%
12 July-December Male not ident Female 36
13 IUIH CONNECT July December 2016 Flexible Funding Allocation OT and Mobility aids Podiatry Nursing services Nutritional Supplements Allied health Medical Supplies 15% 26% 12% 2% 12% 33%
14 IUIH Connect complexities in care Housing Food finance Cultural considerations Transport to medical appointments Client Medications Medical aids Minor home modifications Home support GP community providers
15 IUIH Connect
16 IUIH Connect
17 Uncle P the whole package! Came to the clinic in 2015 after diagnosis of terminal stomach Cancer. IUIH Connect and GP recognized a need for multiple AH services and care coordination and he was put on the CCSS program. IUIH Home help referring to Aged Care for domestic help assistance and transport assistance - to get to chemotherapy appts at RBWH.
18 Holistic approach to care Social Work Dietitian Physio Dental OT Uncle P Podiatry CCSS EP/WIO Aged Care IUIH Connect
19 Uncle P was referred to: Dietetics for review and assistance with nutritional supplements. Physiotherapy due to a significant decline in mobility/endurance and strength. Provided with a home exercise program and CCSS funded walking stick. OT home visit, resulting in shower chair (funded through CCSS) and a referral for a wedge ramp for the front door to HAS. Residual hand weakness from chemo was making opening jars and gripping difficult, so OT review provided (with CCSS funding) a 2 handled cup and jar opener. Podiatry as he was now a high foot risk status due to chemo induced neuropathy. Podiatry provided foot care, and provision and fitting of new shoes. Dental for a check-up which resulted in some procedures and a referral for dentures. Social Work who provided a home visit for assistance with accessing a Health Care Card.
20 Uncle P after 10 months and no longer attending chemotherapy Put on weight and gained some of his strength back, No longer needing the 4-Wheel Walker for most activities. Wanted to become involved in a healthy, social activity so referred to the WIO program and had an Initial Assessment. Receives transport from the clinic to attend WIO, twice a week, which he has done so now regularly for over a year. Continues to have regular check ups and AH input. Continues to surprise his oncologist with the stability of his serious condition and his general health
21 Where to from here MNHHS MSHHS Staffing CN, SW, support workers Integration w/ other programs
22 IUIH Connect Referrals can be found on the iuih website: under Clinical Services contact IUIH Connect directly on Monday to Friday 8.30am to 4.30pm or fax or us on
23 CONTACT DETAILS Helen Quelch - Regional Manager, IUIH Connect & ITC Sandra Blackman Clinical Nurse (North) Ino Bacatan Clinical Nurse (North) Nicky Sun Clinical Nurse (South) Terry Williams Care Coordinator assistant For more information or assistance please call
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