Aboriginal Chronic Care Pathways

Aboriginal chronic care pathways

Illawarra Shoalhaven Local Health District

Duration: November 2014 – December 2016


Aboriginal Australians are known to experience chronic diseases at much higher rates than other Australians, but little is known about the impact of chronic conditions on Aboriginal people, their families and communities, or how their chronic disease is being managed, particularly in urban communities. This study investigated the factors that impact on Aboriginal people’s experience of chronic conditions and its management in the Illawarra Shoalhaven Local Health District (ISLHD) in order to inform improvements in care planning across the care continuum.

What we did

The study commenced in November 2014. It was conducted by a team of Indigenous and non-Indigenous UOW researchers from CHSD, the Faculty of Science, Health and Medicine (Graduate School of Medicine) and the Faculty of Social Sciences (Health and Society) in collaboration with the ISLHD. The research team has worked closely with the project steering committee and relevant stakeholders within the region including Aboriginal community members and organisations to establish and conduct the research.

We addressed the four key study objectives as follows:

  • To describe the extent and type of chronic disease in the Aboriginal population in the Illawarra and Shoalhaven regions, we conducted a targeted review of the literature including peer reviewed journal articles, books and 'grey' literature (McMullen, et al. 2015);
  • To document formal chronic disease management models of care for Aboriginal patients across NSW, we conducted a program design review, involving a desk review of published guidelines for Aboriginal chronic disease models of care and conducted nine interviews with the managers of programs operating in the ISLHD;
  • To explore and document Aboriginal people’s experiences of chronic disease management, we conducted 22 qualitative interviews and four focus group discussions with 27 Aboriginal people managing chronic illness in the community;
  • To identify the strengths and weaknesses of current chronic disease management for Aboriginal people, we conducted 22 qualitative interviews with service providers and systems stakeholders.

The study highlighted the unacceptable rates of preventable chronic disease among Aboriginal people in the Illawarra and Shoalhaven regions and identified the need to strengthen supports offered to chronically ill Aboriginal people, particularly in the hospital-stay and post-discharge periods. Better linkages between health and social services in the region are needed to address the underlying social and cultural determinants of health. The study found that health literacy is a major gap in current supports. The region benefits from a number of Aboriginal targeted chronic disease management programs operated by both mainstream and Aboriginal organisations, but these need to be more widely promoted and enhanced. There is also scope for much improved information about benefits available under the Closing the Gap program, a greater uptake of general practitioner care plans by GPs, and a stronger role for Aboriginal Community Controlled Health Services. A comprehensive strategy to address the Aboriginal health workforce would assist in achieving improvements in each of these areas.

The results of the study are presented in three separate reports - Final Report; Summary Report; and Community Report – all of which were submitted in December 2016.

There are unacceptable rates of preventable chronic disease amongst Aboriginal people in the Illawarra and Shoalhaven regions. There is a need to strengthen the supports offered to chronically ill Aboriginal people while in hospital and in the post-discharge period. 


AHSRI project team: Kathleen Clapham, Joanna Mason, Pam Grootemaat, Nadia Neal, Virginia Marshall, Claire Manning

Collaborators: Scott Winch (Graduate Medicine, University of Wollongong), Kate Senior (School of Health and Society, University of Wollongong)


Last reviewed: 3 August, 2018

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