The Chronic Care Service Enhancement Program

The disparity in life measured in health outcomes and life expectancy between Aboriginal and non-Aboriginal people has been well documented. Aboriginal people living in NSW have a significantly higher incidence of chronic disease than the non-Aboriginal population. Chronic conditions such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer are responsible for 70% of the health gap (ill health and mortality) between Aboriginal and non-Aboriginal people in terms of disability adjusted life years.¹

In response to this, the NSW Ministry of Health is funding the Living Well: the NSW Aboriginal Health Chronic Care Initiative for the development, implementation and evaluation of a range of evidence-based and culturally responsive secondary prevention and chronic disease management initiatives for Aboriginal people in NSW. The target group for the Living Well Initiative is Aboriginal people aged 15 years and over diagnosed with, or at risk of developing, the chronic conditions of diabetes, cardiovascular disease, chronic respiratory disease, renal disease, musculoskeletal and connective tissue disorders and malignant cancer.

The Chronic Care Service Enhancement Program is the most significant investment of the projects funded under the Living Well Initiative. The Program aims to improve access to secondary prevention health services, as well as improving the coordination and management of care for Aboriginal people with, or at risk of, chronic diseases. The Program will enhance chronic care services being delivered under the Chronic Care for Aboriginal People Program by the Aboriginal Community Controlled Health Services (ACCHS) and Local Health Districts throughout NSW.

Nine ACCHS are receiving funding under the Program to implement strategies that will increase the accessibility of services, provide early intervention for clients at risk of chronic disease, and improve the care coordination and management of Aboriginal people with chronic diseases. The Centre for Aboriginal Health has a close working partnership with each service and the Aboriginal Health and Medical Research Council of NSW to ensure the Program is responsive to the needs of each service and local communities.

The ACCHS are implementing a range of specific strategies to improve the reach, screening and management of chronic disease in Aboriginal communities. To increase the number of Aboriginal people accessing the service for the first time or re-engaging with the service, the health services are holding open days and information sessions for local communities, providing outreach services and transport, and improving referrals with other services providers. To increase the number of clients who are screened for chronic diseases in line with evidence-based guidelines, services are providing staff training, increasing opportunistic screening, and improving reminder and recall systems. To improve the management of chronic disease in accordance with best practice guidelines, services are undertaking strategies such as organising regular multidisciplinary team case management meetings, improved care planning and referrals, delivery of self-management strategies and brief interventions to support patients.

Using the program funding, the health services have recruited a range of health professionals to implement these strategies, including Nurse Practitioners, Enrolled Nurses and Aboriginal Health Workers. Services are also able to use funding to source additional services, such as allied health and specialist services, and transport.

The second component of the Program focuses on the Local Health Districts, enhancing funding to the Chronic Care for Aboriginal People Program. A dedicated chronic care clinical position is being established in each Local Health District to provide clinical follow-up to Aboriginal patients with chronic disease within 48 hours of being discharged from hospitals across NSW.

A comprehensive evaluation of both phases of the Program is being carried out by the University of Newcastle to measure the effectiveness and acceptability of interventions being delivered in improving health systems as well as improving measurable health outcomes.