Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia's Northern Territory - Use of the Chronic Care Model

Damin Si, Ross Stewart Bailie, Joan Cunningham, Gary Robinson, Michelle Dowden, A STEWART, Christine Connors, Tarun Weeramanthri

Research output: Contribution to journalArticleResearchpeer-review


Background. Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from chronic illness such as diabetes, renal disease and cardiovascular disease. Improving the understanding of how Indigenous primary care systems are organised to deliver chronic illness care will inform efforts to improve the quality of care for Indigenous people. Methods. This cross-sectional study was conducted in 12 Indigenous communities in Australia's Northern Territory. Using the Chronic Care Model as a framework, we carried out a mail-out survey to collect information on material, financial and human resources relating to chronic illness care in participating health centres. Follow up face-to-face interviews with health centre staff were conducted to identify successes and difficulties in the systems in relation to providing chronic illness care to community members. Results. Participating health centres had distinct areas of strength and weakness in each component of systems: 1) organisational influence - strengthened by inclusion of chronic illness goals in business plans, appointment of designated chronic disease coordinators and introduction of external clinical audits, but weakened by lack of training in disease prevention and health promotion and limited access to Medicare funding; 2) community linkages - facilitated by working together with community organisations (e.g. local stores) and running community-based programs (e.g. "health week"), but detracted by a shortage of staff especially of Aboriginal health workers working in the community; 3) self management - promoted through patient education and goal setting with clients, but impeded by limited focus on family and community-based activities due to understaffing; 4) decision support - facilitated by distribution of clinical guidelines and their integration with daily care, but limited by inadequate access to and support from specialists; 5) delivery system design - strengthened by provision of transport for clients to health centres, separate men's and women's clinic rooms, specific roles of primary care team members in relation to chronic illness care, effective teamwork, and functional pathology and pharmacy systems, but weakened by staff shortage (particularly doctors and Aboriginal health workers) and high staff turnover; and 6) clinical information systems - facilitated by wide adoption of computerised information systems, but weakened by the systems' complexity and lack of IT maintenance and upgrade support. Conclusion. Using concrete examples, this study translates the concept of the Chronic Care Model (and associated systems view) into practical application in Australian Indigenous primary care settings. This approach proved to be useful in understanding the quality of primary care systems for prevention and management of chronic illness. Further refinement of the systems should focus on both increasing human and financial resources and improving management practice. � 2008 Si et al; licensee BioMed Central Ltd.
Original languageEnglish
Pages (from-to)112-126
Number of pages15
JournalBMC Health Services Research
Publication statusPublished - 2008


  • article
  • Australia
  • chronic disease
  • community care
  • follow up
  • funding
  • goal attainment
  • health care delivery
  • health care organization
  • health care quality
  • health insurance
  • health promotion
  • human
  • indigenous people
  • medical informatics
  • patient education
  • primary health care
  • problem identification
  • staff training
  • theoretical model
  • Aborigine
  • cross-sectional study
  • economics
  • epidemiology
  • ethnology
  • health center
  • health service
  • health services research
  • information system
  • interview
  • organization and management
  • statistics
  • Chronic Disease
  • Community Health Centers
  • Cross-Sectional Studies
  • Health Care Surveys
  • Health Services, Indigenous
  • Humans
  • Information Systems
  • Interviews as Topic
  • Oceanic Ancestry Group
  • Organizational Case Studies
  • Primary Health Care
  • Program Evaluation
  • Quality Indicators, Health Care

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