The FlexiClinic in the emergency department at St Vincent’s Hospital Sydney is a model of care for Aboriginal patients that aims to improve delivery of culturally responsive care and reduce incomplete treatment rates.
The model of care was co-designed with Aboriginal and non-Aboriginal staff to address barriers to care. These include long waiting times and cultural disconnection, which have historically led to high rates of incomplete treatment among Aboriginal patients presenting to the emergency department (ED).
The clinic has introduced a flexible care approach with:
- dedicated Aboriginal healthcare staff and clinicians
- immediate alerts upon patient arrival
- 48-hour follow-up for patients who leave before completing treatment.
This initiative has not only reduced incomplete treatment rates for Aboriginal patients, but also fostered a sense of safety and trust, demonstrating the effectiveness of culturally responsive care in addressing healthcare disparities.
The clinic is a culturally responsive model of care. It supports the Closing the Gap Priority Reform areas by addressing shared decision making and embedding cultural safety within healthcare delivery.
It also aligns with the strategic direction of the NSW Aboriginal Health Plan 2024-2034 by providing holistic, person-centred care and strengthening the Aboriginal health workforce. Recognised for its impact, this model serves as a blueprint for integrating culturally safe practices in emergency care settings.
Addressing high rates of incomplete treatment
Historically, the St Vincent’s Hospital ED has had one of the highest rates of incomplete treatment for Aboriginal and Torres Strait Islander patients in NSW EDs.
In the 2018-19 financial year: 19% of Aboriginal patients presenting to the ED did not complete their treatment; 8% left at their own risk and 11% did not wait for treatment. The Ministry of Health’s target was 5%. These statistics highlighted systemic barriers such as long waiting times, cultural disconnection and historical mistrust of healthcare institutions.
Aboriginal staff played a pivotal role in this project from the outset, identifying challenges and shaping the clinic's culturally safe model. We began with a comprehensive review of incomplete treatment in the ED for Aboriginal patients – we found that our rates were more than double the national average. This alarming statistic prompted the formation of a multidisciplinary working group, including Aboriginal Health Unit staff, ED clinicians, nursing staff and hospital executives.
Together, the team conducted a root cause analysis to identify barriers such as long wait times, cultural disconnect, and historical mistrust of healthcare institutions. This included undertaking a clinical redesign through the ACI’s Centre for Healthcare Redesign.
Our consultation with staff and consumers revealed the following challenges that were contributing to incomplete treatment:
- inconsistencies in documentation by ED staff when classifying patients as ‘Did not wait’ and ‘Left at own risk’
- long waiting times
- limited access in the ED to social workers and Aboriginal Health Workers after hours and on weekends
- insufficient staff training, education and experience in providing culturally safe and appropriate clinical care for Aboriginal and Torres Strait Islander patients.
Aboriginal leadership integral from the outset
To address these challenges, we implemented 4 major interventions.
- Staff specialist and registrar-led care (known as the FlexiClinic) – an allocated medical team on all ED shifts accountable for all Aboriginal and Torres Strait Islander patients.
- Reallocation of Aboriginal Health Worker shifts – we developed an afternoon/evening shift to cater for the higher proportion of presentations at this time, additional to established day and weekend shifts.
- An education and training package for all ED staff on culturally safe and trauma-informed care, to build competence and confidence.
- Community engagement through developing (and continuing to strengthen) partnerships with ACCHOs across NSW through Aboriginal Health Plan consultations, Aboriginal Chronic Care Coordination and formal partnership agreements. This helped to foster interconnected community care and the support role of St Vincent's in the health continuum of Aboriginal and Torres Strait Islander patients.
Aboriginal leadership was integral from the beginning. The Aboriginal Health Unit, led by Aboriginal health professionals, co-designed the clinic's model, ensuring cultural safety and responsiveness. Key interventions included the establishment of a flexible clinic model operating 24/7; immediate alerts to AHU staff upon Aboriginal patient presentation; and the implementation of 48-hour follow-up for patients who left before completing treatment. We extended AHU service hours to align with peak presentation times and mandated cultural competency training for all ED staff.
Regular monthly review meetings, involving medical, nursing and Aboriginal Health Unit staff, were established to assess cases of incomplete treatment. Patient feedback from 48-hour follow-up calls was also incorporated, allowing for ongoing refinement of the clinic's practices and ensuring that patient voices remained central to service improvements. By introducing the measures above, the clinic addressed barriers such as long wait times and cultural disconnection.
Increased ED presentations and early reduction of incomplete treatment rates
Since implementation of the FlexiClinic model in 2020, there has been a 7% year-on-year annual growth in ED presentations by Aboriginal and Torres Strait Islander people, and a decrease in incomplete treatment rates, reducing from 19.8 to 7.5% on average in 2021.
However, the early outcomes of the model could not be sustained, with ‘Did not wait’ rates increasing between December 2021 and April 2024, noting these were still below the baseline median (11.9%). Upon review it was determined that staffing and recruitment challenges were the main drivers of the inability to sustain gains.
To address these challenges and to extend the effectiveness of the model, we implemented the 'Gold Team' in 2024 – this team provide rapid access to staff specialist review between 6pm and 11pm, 7 nights per week. We employed Aboriginal Health Practitioners providing a weekend clinical service with the multidisciplinary team to focus on culturally safe practice within the ED. Professional development of transitional Aboriginal Health Practitioner roles is also provided (as a 1-year program, 1 day a week), to ensure appropriately trained staff and optimal staffing levels.
After further review of the FlexiClinic project, we looked at the effect of including a senior clinician to coordinate the FlexiClinic. Based on the analysis, we introduced a new role, the Aboriginal Acute Complex Care Coordinator. The role is to offset the load of the Aboriginal Chronic Care Coordinator, and address patients who present with complex care and no chronic illnesses. We are considering renaming the FlexiClinic to a name that better reflects the service for Aboriginal and Torres Strait Islander people who present to ED.
We aim to empower the community in engaging with our service, to map the patient journey to ensure continuity of care and to minimise readmissions through community support networks. We are also in the process of planning a purpose-built, culturally appropriate space for Aboriginal and Torres Strait Islander people as an alternative option to the ED waiting area.
We acknowledge and thank the following for their sponsorship of this project:
- Professor Anthony Schembri
- Pauline Deweerd
- Todd McEwan
