This analytical paper is about one of the consumer from Aboriginal and

This analytical paper is about one of the consumer from Aboriginal and Torres Strait Islander (ATSI) background, who was one of the consumer looked after by Eastern Community Mental Health (ECMH). For the consumer privacy and confidentiality name of the consumer has not used throughout the paper. Hypothetical name James was given to make easy for readers to understand his journey and illness.The paper mainly discussed about the consumer journey from home to the day presented in hospital and also ongoing support and care consumer is getting form the ECMH team. First, background of the patient will be presented followed by five dimensions of health and the factors affecting access and quality of care. Second, chronological mapping and important aspects of consumer will be discussed. Then, issues of the consumer will present along response with those issues. Finally, some recommendations that need to consider in practice with country ATSI patient will discuss and conclusion will finish the paper. IntroductionJames is 42 year old, Aboriginal man, currently lives with his long-term partner in Adelaide eastern suburb with their four children. James was diagnosed with Schizophrenia, acute psychotic disorder, Hepatitis C and had history of intravenous drug user, and also ethyl alcohol (ETOH) abuse. He also had suicide attempt on two occasions overdosed on poly-pharmacy. South Australian Ambulance Service (SAAS) presented James in Royal Adelaide Hospital (RAH), emergency department in 22/1/ 2014 with an overdose of multiple medication. He was settled on 23/1/2014 and denied any suicidal ideation or thoughts, and was discharged agreeing to follow up with community mental health, and general practitioner. After two days, his partner reported second suicide attempt and again presented to RAH. After discussion with healthcare team and review by consultant, James was transferred to acute setting for close monitoring. With improvement he was discharged on 11/02/2014 as an inpatient and follow up his progress by community mental health team through home visit and monitoring his medication frequently. Even though he was under close supervision by ECMH team, he was presented three times in RAH Ward C3 after he was discharged in February 2014. On 27/03/2015 he was diagnosed with unspecified Schizophrenia.Due to his multiple presentation in hospital and continues to avoid mental health services he was on Community Treatment Order Level 1 under Mental Health Act 2009. He has to attend depot every week for his medication due to non-compliance at home. Even though his suicidal ideation and violence against partner is at low risk he is still at high risk of self-harm, and drug and alcohol use. ECMH team is monitoring his illness by visiting him at home once every week.Five Dimensions of Health in relation to James caseDimension of Health Existing Situation & Strengths New challenges once began journeyPhysical / Biological • Acute Mental illness (Schizophrenia and psychotic disorder).• Lives in one of the Adelaide metropolitan suburb. • More prone to loose his independent. • May loose his family and relatives.Psychological / Emotional • Isolated and Distressed with mental illness.• Feels racism and discrimination in community where Indigenous people are in minority.• Stress about the cost of living and his illness, unemployed. • Had 4 children and stressed about their future.• Stress to go depot for his medication. • Chance to develop more severe illness with stress.• May not like people from other race and culture due to being discriminated. • May not compliant with depot medication due to frustration from every visit.Social & Wellbeing • Lives in Adelaide metropolitan area where there are minority Indigenous communities.• Feels like isolated from the community.• Wife is supportive, so he is trying to manage his illness.• Good relation with his sister but evasive with friends. • Being isolation from society he will be more vulnerable.• No Indigenous community around isolated form community. Spirituality • Respect Indigenous values and beliefs. • Believe in traditional way of life and death. • Struggle to reconnect his culture. Cultural Integrity • Loves to participate Indigenous programs but there was not organised in his community. • Severe illness and language limit participation in cultural program.Factors affecting James access quality of care Policy makers and general public are putting effort on healthcare priorities for ATSI people living in remote areas. However, ATSI people living in urban area are not given priority as they should be given. • Location/Environmental risks: Even though James lives in metropolitan area there are various factors, which restrict him quality of care. Kerry & Pauline 2010, mentioned there are number of health conditions, where Indigenous people living in urban area are higher than remote areas, where access to service should not be barrier. Other issues are dangerous dog loose in the house, unknown visitors in home, difficult to arrange time, makes difficult to ECMH team member home visit for his medication and risk assessment. • Alcohol and Substance use: Use of illicit drug and substance use makes his mental illness more severe and cannot locate him at home to access his mental illness and for medication. Alcohol and substance use are the cause of wide range of social problems among Aboriginal Australians and have significantly dangerous impact in their health (Edwards et al 2010).• Language: Even though he can speak in English, due to his illness conversation is not cohesive. ECMH team member and his care coordinator finds difficult to communicate and ultimately quality of care was affected.• Financial resources: Unemployed, does not have any financial income for his treatment and have to rely on government payment. Introducing co-payment doctors are significant barrier to accessing health service and medical prescriptions. Travelling to depot every week is very expensive as well.• Cultural Issues: Lack of cultural friendly clinic and healthcare workers from Indigenous background quality of care was not delivered, as it should be. Inadequate knowledge about Indigenous culture, awareness and lack of respect by healthcare workers, may be barrier for the achievement of positive health outcome (Kerry & Pauline 2010).Even though health care services in urban area are better than remote and rural, lack of research into the health of urban Indigenous people shows health disparity is smaller than Indigenous people living in remote areas (The Medical Journal of Australia 2015). Research shows barriers to access quality care for Indigenous people living in urban areas are classified as problem of availability, affordability, acceptability, and appropriateness (Margaret & David 2008). ATSI people living in urban are less satisfied than remote ATSI people with their access to health care. Table: Comparing factors affecting access in quality of care in Local and City health services.Factors Country/Remote health services City health servicesLocation/Setting • Healthcare setting in remote has limited and inadequate resources.• Have to travel long way to access territory care needs. • ATSI people living in city area are disproportionately concentrated within socioeconomic suburban areas with relatively poor access to health service.• Better healths care access compare to remote area. Burden of illness • Poor socioeconomic status, poverty, education are the burden of illness in remote areas.• Lack of healthcare professional/ workforce.• Use of alcohol and drug are the barrier for health care and burden of illness for ATSI community. • Acute hospital setting is very difficult to understand with complicated medical terms used by staff.• Use of alcohol, illicit drug and substance use makes ATSI people illness more severe and does not attend or seek health care services.Language / Communication • Lack of interpreter makes difficult to get quality health care.• Lack of proper communication method they could not reach to the mainstream health care providers. • Low literacy level and language are reason ATSI people in urban areas find difficult to read information as well as difficult to understand doctors or nurses medical terminologies. • Lack of Indigenous health care workers.• Communication done through emails and faxes find hard to understand by ATSI people.Financial resources • Hard for people who have little or no extra money to transport for treatment. • Unemployed and have to rely on Centerlink payment for all of the household costs. • Unemployment and poor socioeconomic status are the major barriers for ATSI people getting quality of care. • Could not afford GP fees and prescription.• No telephone/mobile phone to make appointment.• Could not afford taxi charges to attend appointment.Aboriginal/non-Aboriginal • Indigenous people are experiencing disadvantaged group in mainstream health system.• Health care services are also different for ATSI people and Non- Indigenous people. • ATSI people living in urban area are invisible minority and exposed to discrimination and treat that they are not real Aboriginals.• Feel discriminated in GP services.Chronological MappingJames started his mental illness from 2004 and there are number of episodes he had in his journey. Multiple times presented in hospital, referrals to Glenside and frequently visit to depot for medication made James journey quite lengthy and hard to manage as well. James partner was so supportive, which makes easy for him otherwise he will suffer more than what he is suffering now. Chronological map below gives more information about how James was travelling through his journey. Table: Chronological Mapping PatientHistory Diagnosis/Referral Trip to city/ECMH In hospital Discharge / transfer Trip home Follow-UpPatient Journey Middle aged Aboriginal man experiencing severe mental illness Take long time to diagnosed.Suffering from long time.Multiple referrals to different settings. Community mental health workers provide services occasionally.Ambulance and Taxi. Uncomfortable to hospital settings.Detained under Community Treatment Order feels like locked up. Discharged to multiple settings in Glenside Campus.Have to attend ECMH clinic for depot medication By TaxiSometimes ECMH team provides transport. Visit every week to depot clinic for medication. Could not attend due to transport and costs.Patient priorities, concerns & commitments Involvement in treatment plans. Medication after diagnosis and commitment to compliant with medication. Transport to the depot for regular medication. Multiple trips Feared with detention. Scared from other patients. Collect information for recovery. Still on medication and not recovered fully. Regular follow up in scheduled date and time.Health service priorities Treating mental illness. Find appropriate treatment for the Patient. Specialist doctors and other health professionals Patient safety.Regular monitoring. Organise medication, and referrals for Glenside. Ambulance ECMH team will continue home visit.Service gaps Nil Long process for referral. Expensive taxi and ambulance charges Lack of Indigenous health care worker/ Feels discriminated. Not Organised. Taxi NilResponses to gaps Nil ECMH team visits. Sometimes ECMH provide transport Interpreter should available if there is no Indigenous health worker. Should organise properly for referrals and medications. ECMH transport to home ECMH visit every week. Important aspects for JamesDespite the fact that James has mental illness there are good aspects as well. He lives in metropolitan suburb, which is easy access for better healthcare facilities compare to remote area. He had a supportive wife and helps him with his daily activities as well as monitor medication compliance and if not reports to healthcare workers. She also supports in communication and arrange transportation, appointments for his daily depot medication. James is one of the consumers who have been looked after from ECMH team and also have allocated care coordinator, support worker for ongoing assessment. Even though he is unemployed, most of the service is bulk billed and most of the time ECMH team provides transport for his doctor’s appointment and depot medications. He had a good relationship with his sister. Aboriginal people are tolerant and able to cope with the support of their strong kinship and diversity.Issues of the patient and response to those issuesThe main issue for James to treat his illness is lack of cultural friendly healthcare setting, language, use of alcohol and substance use, and transport. • Different concept of health and treatment of illness: In Indigenous culture health means not only physical well but as a holistic understanding of physical, mental, emotional, spiritual and cultural well of the whole community (National Aboriginal Community Controlled Health Organization 2015). James does not believe he had a mental illness when community health care workers and social workers visit his home to assess him. To respond this situation Aboriginal healthcare worker involvement may help and educate him about his illness and medication and treatment available. Also with cultural respect into healthcare service and delivery will improve outcomes and quality in an efficient and effective way (Kerry & Pauline 2010).• Language: Even though James can speak simple English language it is hard him to understand when healthcare workers use more medical terms. Whenever it is time to explain about the treatment procedure, James stress a lot and feels irritable and uncomfortable. Many patients are being miss diagnosed, or wrongly treated, due to English is limited to Indigenous people and few health care workers speaks Indigenous Languages (Australian Broadcasting News 2015). To respond the gap and barrier in communication, we can use the interpreter if available, use the open end questions, do not make hypothesis or assumptions, seek family or friends help to communicate, use body language, understand the culture and be nice and polite at all time. • Use of Alcohol and Substance use: One of the main issues about James illness is use of alcohol and substance use. Even though there are lots of referrals done to cease alcohol and substance use, which did not work in James habits. However, through the help from Drug and Alcohol Service South Australia (DASSA) he did cut down usage but hard to cease drug and alcohol. Nursing intervention to cease alcohol and drug are educate the patient, referrals to drug and alcohol service providers, give them alternative option to drug and alcohol. National Drug Strategy Aboriginal and Torres Strait Islander Peoples Drug Strategy has been developed to help National Drug Strategy a plan focusing specially on alcohol and substance use among Aboriginal Australian (National Drug Strategy 2015).Things to consider in practice with country and remote ATSI peopleEven though 2.5% of Australian populations are identified as Indigenous and among them only 26% lives in remote and 70% of Australia land mass is covered by remote and rural area (Australian Bureau of Statistics 2007). It is obvious that there are issues and challenges of living in remote areas, healthcare workers should follow and understand their culture, values, beliefs and traditions, which impact in practice. • Understand the Indigenous people and culture: Indigenous health and culture are inter-related therefore understanding the Indigenous culture is important to deal with their health. Kerry & Pauline 2010 mentioned, various approaches to Indigenous health have viewed culture as a key determinant that can be managed with cultural awareness, or cultural competence as a part of health care providers. While on practice every health care worker should be aware about culture sensitivity and safety as a code of conduct. • Communication and Language: There has been error in diagnosis or treatment due to miscommunication between patient and health care workers. To avoid bad consequences from language and communication health care workers should aware about language usage, use of plain English and limit medical jargon, body language, use visual aids when appropriate. Building trust and rapport with client and ongoing training and support to workers can also help to communicate better in Indigenous health practice.• Understand Indigenous health: Indigenous people take health as a not just physical well being but combination of physical, social, emotional, spiritual, and cultural. It is a holistic approach and from the perspective of Indigenous people, health has little to do with physical state and much more to do with social and emotional states (Kerry & Pauline 2010). In practice as well health care professionals should focus as whole community health rather than individual. • Indigenous health priorities: Major chronic diseases facing by Indigenous people living in remote areas are cardiovascular diseases, diabetes, heart disease, kidney disease, mental disorders and others. A study done by The University of Queensland in 2003 shows, cardiovascular and mental disorders are the two leading contributors to the disease burden in Indigenous Australians. Plans and policies should me done according to the most prevalent disease in the community and practice should be done accordingly. • Indigenous health workers: Health workers from the same culture and community compare to other community make huge difference in Indigenous health practice. They have a better understanding of culture, language, their people, in combination with clinical skills (Kerry & Pauline 2010). Conclusion Even James lives one of the Adelaide suburban areas his health status is similar to Indigenous people living in urban areas. Kerry & Pauline 2010, mentioned same health problems are facing by both Indigenous people living in remote and urban areas even there are better access and acceptability of health services in urban areas. This need to be address and government should give same priority to urban Indigenous people as they give priority to remote Indigenous people. ReferenceAustralian Broadcasting News 2015, Doctor-patient language barrier a concern

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