The life expectancy gap for Indigenous people in Australia is 13 years and most of this gap is due to preventable chronic disease in adults. Once people have these conditions, many complications can be prevented with good primary-level chronic care.  This project aims to introduce and evaluate a new strategy for integrated community-based, intensive chronic condition management in rural and remote Indigenous primary care services:  Diabetes, hypertension, coronary heart disease (CHD), renal disease and chronic obstructive pulmonary disease (COPD).

Proposed strategy: An intervention in 3 phases over 5 years:
1. A trial of intensive locally delivered chronic care in 6 out of 12 participating sites in FNQ with clear clinical and QoL outcomes;
2. Review of lessons learned in the first phase trial, modified as necessary to reflect findings, a discussion about generalisability to the “control” sites in the trial, with an implementation plan and the development of a curriculum package for the program and;
3. In collaboration with the trial partners, a more general system rollout of lessons learned, with potential regional implications of a patient-centred service delivery model, including workforce and funding applications.

Phase 1: Cluster randomized trial of locally managed chronic care in rural north Queensland (n=12 participating primary care services, with 6 intervention sites and approximately 360 participating Indigenous adult clients in total), over 3 years.

Participants and inclusion criteria:
Clinics: Located in rural north Queensland, with a significant Indigenous population, and with a primary health service provided either by Queensland Health or a local community-controlled Indigenous Health Service.

Patients: Diagnosed at least one year prior to recruitment with at least one of the 5 identified chronic conditions.  Excluded will be those with major mental illness and those over age 65. Adults with established diabetes (diagnosed for more than one year) and with HbA1c >8.5 will be counted for the primary outcome measure.

Details of the Intervention
An Indigenous clinical support team (ICST) will train and mentor community-based IHWs to deliver intensive management for 5 common chronic conditions, with clear clinical and service goals, and will include specific training and practice.

Main outcome measures: Improved glycemic control, hospitalisations for complications, QoL, other clinical process measures.

A Partnership between Queensland Health, Apunipima Cape York Health Council, University of Queensland and University of South Australia, with NHMRC.