How can we make HITH more culturally safe?

Hospital in the Home (HITH) – a care model that has exploded in popularity in recent years – is celebrated as a convenient alternative to hospital-based care. But for Aboriginal and Torres Strait Islander people, receiving care at home can be more than just a convenience.

In some cases, their health could depend on it, given the higher DAMA (Discharge Against Medical Advice) rates observed in hospital-based First Nations patients, compared with those receiving care via HITH.

But even though HITH programs may have better adherence and health outcomes for Indigenous patients, they are not always equitable.

As Dr Carmon Guy of Cairns Hospital explains ahead of the Hospital in the Home Conference, more work is still needed to ‘close the gap’ in a HITH context.

Leading the way

With 20 percent of HITH patients at Cairns Hospital identifying as Indigenous, Dr Guy and her team are taking measures to ensure these services are culturally safe.

“HITH has the potential to reduce institutional barriers to acute inpatient care, which can be experienced by First Nations clients.

“For example, we know that First Nations people find it less intimidating to be treated at home surrounded by family and, therefore, much less likely that a DAMA in this setting.

“We also know that, because of this added comfort, Indigenous people can be more receptive to care and health advice in general.

“But despite these advantages, we know there is more we can do to refine HITH and close the gap further,” she said.

Indigenous health worker

With this in mind, Dr Guy is currently recruiting an Aboriginal and Torres Strait Islander health worker (A&TSIHW) to join the Cairns Hospital HITH service – a move that will enhance care and improve communication between staff and patients, she says.

“We felt it was important to have Health Workers employed within Hospital in the Home that could provide clinical care and also advocate for a culturally safe, accessible and responsive HITH service that meets the clinical, social and cultural needs of our patients.

“Health workers support client engagement and self-management within a framework of culturally safe care. Alongside their hospital counterparts, Indigenous Hospital Liaison Officers, they are the only front-line professionals in the state advocating for culturally safe care at the whole-of-service level.”

The role of a First Nations health worker will be diverse, but generally serves several functions.

#1 – Advocate

With many Indigenous people speaking English as their second or third language, Indigenous health workers have an important role to play in advocating for their patients.

“Health advice often involves complex medical jargon, which can be difficult to understand. Having someone there to facilitate and advocate for the patient could make all the difference to their health outcomes,” Dr Guy said.

#2 – Culturally safe advice

In a similar vein, Indigenous health workers could ensure that any medical advice considers the patient’s cultural and social context and is administered in a culturally safe way.

“This could mean listening to and respecting the patient’s preferences, even if they are not considered medical best practice,” Dr Guy said.

#3 – Promote adherence

If the patient wishes to discontinue their care against advice, or avoid an escalation, the health worker can assist and advocate for the individual.

“There may be patients who wish to terminate their care because they don’t feel culturally safe, in which case, the health worker can take measures to ensure the service is adaptable and responsive so they feel more comfortable.

“Alternatively, some may have competing cultural demands which take priority over their health. For example, they may be a leader in their family and have additional responsibilities, which prevent them from prioritising their own care. Here, the health worker can assist the client and advocate to make necessary accommodations.”

In both scenarios, communication would be key, Dr Guy said.

“If an escalation of care is required and the patient is unsure about returning to hospital, the health worker could help them weigh up the risks and benefits of remaining at home, and support the service to broker safe-alternatives to that care.

“They address any needs and concerns through really good communication with the patient and their family; and work with patients in a culturally safe way to navigate whatever barrier they have.”

#4 – Reporting feedback

In the event a DAMA occurs, the Indigenous health worker could help give context.

“It might be that the patient has some ‘sorry business’ coming up that they didn’t want to share with a doctor or nurse.

“The health worker could listen to and understand their cultural reasons for not wanting to access care – as well as helping them understand the health implications of refusing it.”

Moving forward

Dr Guy and team are making headway with their ‘close the gap’ efforts and are among the first, nationally, to recruit an Indigenous health worker to HITH.

However, they are still ironing out challenges to ensure the care process for First Nations clients is smoother.

“When patients are coming down from the Cape, we need to house them in hotel rooms – and these often don’t have kitchens or they have a medical condition which effects their mobility. It is the responsibility of the service to ensure patients have access to healthy food and social support.

“Patients from all over Far North Queensland travel to Cairns to receive care. Patients can be separated from their families and communities for months. They are at significant risk of social isolation and financial stress. It is important that our HITH service is equipped to identify and address the social needs of patients as well. ”

Moving forward, Dr Guy and team are also designing the service to support direct community referrals and hospital avoidance.

“We are working with our local Aboriginal Community Controlled Health Service and other community health services to provide hospital level care at home, wherever possible,” she said.

Further insight

Talking more about the Cairns Hospital HITH service, Dr Carmon Guy will present at the upcoming Hospital in the Home Conference, as part of Connect Virtual Care.

One ticket to Connect Virtual Care gives you access to three conferences: Medication Safety & Efficiency, National Telehealth and Virtual Care, and Hospital in the Home.

This year’s event will be held 2-3 April 2025 at the Hilton Sydney.

Learn more and register your tickets here.

About Carmon Guy

Dr Carmon Guy is Clinical Director of Cairns Hospital HITH service and also a General Practitioner in Cairns. Working between these two roles she has developed a strong deisre to strengthening the interface between the hospital and community-based care, particularly for First Nations people.