Lighthouse is a project that is jointly sponsored by the Heart Foundation and the Australian Healthcare and Hospitals Association. Its aim is to drive change in the acute care setting through the implementation of quality activities that improve care and outcomes for Aboriginal and Torres Strait Islander peoples experiencing coronary heart disease. There are disproportionate numbers of deaths from coronary heart disease in Aboriginal and Torres Strait Islander peoples. It is the leading cause of death among this population, who are 60% more likely to die from this condition.
Aboriginal and Torres Strait Islander Australians are also dying at a younger age, with 81% of deaths in those under 75 years, in contrast to only 24% nonIndigenous deaths in this age group1. Aboriginal and Torres Strait Islander peoples are more likely to be admitted to hospital for Acute Coronary Syndrome (ACS) episodes — namely, for a heart attack or angina — and are more likely to die in hospital or leave against medical advice. However, while in hospital, they are less likely than non-Indigenous Australians to undergo coronary tests and procedures. Hospitals have a critical role to play in improving access to evidence-based care and addressing disparities in care for Aboriginal and Torres Strait Islander peoples.
In 2012, Phase 1 of the Lighthouse Project involved reviewing the literature and learning from 10 health-care services that were recognised by their peers as providing exemplary care. Four domains were identified as key to establishing best practice care for Aboriginal and Torres Strait Islander peoples with ACS. These domains included cultural competence, use of clinical care pathways, having a skilled workforce and appropriate governance.
In 2013, Phase 2 of the Lighthouse Project began, with this work due to finish on 1 June 2016. Phase 2 aims to drive change in eight pilot hospitals through the implementation of quality improvement activities across the four domains that improve care for Aboriginal and Torres Strait Islander peoples experiencing ACS.
The domains identified in Phase 1 along with elements such as better identification of Indigenous patients, effective partnerships with local Aboriginal and Torres Strait Islander communities, fostering of clinical champions and expanding the Aboriginal health workforce, were developed into a toolkit.
The toolkit provides health practitioners with practical activities that can drive change, address disparities and improve outcomes for Aboriginal and Torres Strait Islander people who present to hospital with ACS. Eight hospitals across Australia were recruited as pilots to test the toolkit including Liverpool Hospital, Coffs Harbour Health Campus and Tamworth Hospital in New South Wales, Bairnsdale Regional Health Service and St Vincent’s in Victoria, Princess Alexandra Hospital in Queensland, Royal Perth Hospital in Western Australia and Flinders Medical Centre in South Australia. Each health facility has concentrated its efforts on one of more of the domains in order to improve access and appropriate care for Aboriginal and Torres Strait Islander patients with ACS.
Phase 3 has recently been approved with the toolkit to be extended to a further 10 hospitals.
Using the Lighthouse toolkit to overcome barriers
The toolkit is currently being tested to see whether it assists in achieving system change and delivers better outcomes for Aboriginal and Torres Strait Islander peoples. Two of the four domains are highlighted here to provide examples of how frontline staff are using the toolkit as part of continuous quality improvement using the “plan, do, check, act” cycle.
Domain one — Cultural competence
Identified barrier: More than 25% of Aboriginal and Torres Strait Islander peoples have reported problems accessing health services. Access issues are higher for those in remote areas and it has been found that some health service staff appear to lack empathy and demonstrate outright antagonism towards Aboriginal people.
Cultural competence is critical to providing quality care to Aboriginal and Torres Strait Islander peoples and it requires a system-wide approach that is embedded in the planning, implementing and evaluating of services. The eight pilot hospitals have employed creative solutions and are driving system changes while shedding light on the patient journey through their hospitals. Some of the strategies being implemented through using the toolkit include:
• Modifying the delivery and target audience of cultural competence training
• Making changes to the hospital environment including culturally safe and inviting rooms for families to meet in and engaging local artists to develop artwork to lead patients to the Aboriginal Liaison Officer or family meeting rooms
• Developing culturally appropriate resources tailored to each community that explains what to expect when presenting to hospital for ACS, how to prepare for tests and discharge letters
Domain two — Clinical care pathways
Identified barrier: Aboriginal and Torres Strait Islander Australians are less likely to undergo a coronary procedure than non-Indigenous Australians.
Implementation of the toolkit enables compliance with the Australian Commission of Safety and Quality — Acute Coronary Standards and assists hospitals in complying with other key standards. The toolkit also incorporates a large number of the Better Cardiac Care Priority Actions. In short, the use of evidence based care pathways will drive change for Aboriginal and Torres Strait Islander patients who are vulnerable and often slip through health care gaps. In some pilot sites emphasis is being placed on handover and discharge planning, as these transition points are important to ensure good communication and planning with patients, families and other health care providers. All pilot sites strive to have productive working relationships with local Aboriginal Community Controlled Health Services to make transition back into the community setting as seamless as possible.
• Some hospitals are supplying all medications at discharge for Aboriginal and Torres Strait Islander cardiac patients to increase the accessibility of medications at home
• Aboriginal Liaison Officers (ALO) are using the Patient Flow Portal to aid screening and prioritisation of workload so they can attend cardiology meetings and discuss complex patients
• Improvements in care planning and discharge planning ensure Aboriginal inpatients (particularly those at high risk of readmission) are provided with appropriate discharge instructions by a multidisciplinary team including the ALO