Budyari Aboriginal Community Health Centre
The Budyari Aboriginal Community Health Centre is located in Miller, a suburb in south-west Sydney. Miller is among the most socio-economically disadvantaged suburbs in the greater Sydney area. (1)
In NSW, many principles of the Patient Centred Medical Home model are already realised through Aboriginal medical services and Aboriginal health centres.
Budyari Aboriginal Community Health Centre houses the South Western Sydney Local Health District's Aboriginal Chronic Care Team.
It also incorporates a vast array of visiting health services, delivered by a range of specialists and allied health professionals. These specialist clinics include endocrinology, nephrology, cardiology, gastroenterology and addiction medicine.
Other health services available on-site include drug and alcohol services, mental health services, dietetics, exercise physiology, and a general practitioner (GP) who attends 1 day a week. Social services such as Centrelink and Legal Aid also regularly attend the centre. A full time social worker will soon be employed to support the Aboriginal Chronic Care Program.
The centre has strong links to Gandangara Health Service, which provides a GP who conducts in-reach to the centre 1 day a week. There is also reciprocity between the services in relation to referrals and joint care coordination of shared clients.
The centre used negotiation and developed practical partnership agreements to establish these connections with primary care, community health, local health district services and social services. These agreements are written clearly, and outline regular times and dates for service provision. Developing these connections and levels of trust doesn’t happen quickly; at Budyari it was the result of many years of work.
The chronic care program run from Budyari is managed by a team that includes two Aboriginal health workers, along with a clinical nurse specialist, renal clinical nurse consultant, dietician and a service manager.
The program has approximately 200 patients on its books who receive active care coordination and case management. To coordinate patients' care needs, the program undertakes health assessments, develops collaborative care plans with GPs, speaks directly with the various care providers, and makes connections with social services when required. Visits to local health districts to connect with their staff lead to more referrals to the program, because the staff learn about the service, and have a level of trust with its clinicians. The program's focus on improving referral pathways from hospital, through the 48-hour follow-up program, ensures timely patient engagement post discharge.
At Budyari, the full range of patients’ needs are assessed. Housing is a major cause of concern for many who use the centre. Housing stress can directly impact a person’s health by minimising their capacity to self-manage their health conditions. By expanding the scope of the health centre to include the social determinants of health, the service engages in preventative health, and provides a person-centred service rather than a disease-centred one.
- Australian Bureau of Statistics. New data from the 2011 Census reveals the most advantaged and disadvantaged areas in New South Wales [Internet]. Canberra: Australian Bureau of Statistics; 2013 [cited March 2017]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mediareleasesbyCatalogue/4DC6126B38D9921BCA257B3B001AF6E8?OpenDocument