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Chronic Care for Aboriginal People Program

Culture Health Communities (CHC) | Model of Care | 48 Hour Follow Up

Culture Health Communities (CHC)

Culture Health Communities Knockout Challenge 2012

NSW Health is partnering with the NSW Rugby League to reduce the rates of chronic disease in Aboriginal communities. This new initiative is part of the Culture Health Communities strategy to improve the health of Aboriginal people. The NSW State Knockout Challenge 2012 is a weight loss challenge for Aboriginal communities. Please click on the following links for further information regarding the NSW Knockout Challenge 2012.


Information Sheet


In June 2008 NSW Health launched a new direction of Chronic Care for Aboriginal People programs and initiatives. This was driven by a number of recommendations resulting from the Redesign Project Walgan Tilly.

This means that all existing and new initiatives designed for Aboriginal people with a chronic disease are now under the strategic program direction of Chronic Care for Aboriginal People - CCAP. This portfolio was previously managed and monitored by the Health Service Performance Improvement Branch. From July 1, 2010, the CCAP Program is part of the Chronic Disease Management Office with a Memorandum of Understanding with the Centre for Aboriginal Health.

The former programs

  • Aboriginal Vascular Health Program (AVHP)
  • Aboriginal Renovascular Program
  • Aboriginal Chronic Care Area Health Service Standards (ACCAHSS)

now collectively form the Chronic Care for Aboriginal People Program as does the associated funding allocated to these programs.

Bronwyn Bancroft created the CCAP logo which symbolises a holistic approach to health. The focus is not just on the patient but on the family. The colours in the logo represent the connection to country.

The Walgan Tilly Redesign Project had a two year implementation period from June 2008-June 2010. During this time, each Area Health Service implemented local solutions specific to the needs of their communities. At a state level, work began on 6 state-wide solutions as listed below:

State-wide Walgan Tilly Solutions:

  • Models of Care for Aboriginal People
  • Greater Aboriginal Cultural Awareness and cultural sensitivity of services - Aboriginal Workforce taking the lead
  • Integration of Aboriginal Health and Chronic Disease mainstream services
  • Justice Health Linkages
  • Improved access to primary care - Centre for Aboriginal Health taking the lead.
  • Improved data quality - by promoting identification.

Model of Care

The development of a Model of Care (MoC) for Aboriginal people with a chronic disease is one of the state solutions resulting from the Walgan Tilly Redesign project which commenced in 2007. This was the first Aboriginal Redesign project facilitated by the NSW DoH with all Area Health Services including Justice Health and some Aboriginal Medical Services. It is due for completion in July 2010.


Eight fundamental elements (shown in diagram) were identified as being essential to the model of care for working with chronic disease in Aboriginal communities. They are Identification, Trust, Screening and Assessment, Clinical Indicators, Treatment, Education, Referral and Follow up.


These eight elements that make up the model have been evolving in Aboriginal Health since 2000 with the establishment of the Aboriginal Vascular Health Program (AVHP). In 2005 the Aboriginal Chronic Care Area Health Service Standards (ACCAHSS) were introduced to mainstream services to support this work as it was building capacity and strength that required the system to respond differently to cater for the needs of Aboriginal people with a chronic disease.


Walgan Tilly, through the Redesign process, identified the successful elements of this work that was happening in pockets of programs across the state. The model of care brings all the evidence of what works well for Aboriginal people into a package of how to deliver services to Aboriginal people with or at risk of developing a chronic disease.


This model complements and provides a practical approach for existing structures and initiatives that support improving health outcomes for Aboriginal people with or at risk of developing a chronic disease. It can be used by any health service providers as a framework to review and map this model to their existing programs or new strategies that is modelled from best practice across the state. This model also allows for the identification of gaps and opportunities at a local and state wide level to maximise existing resources or build business cases to provide new initiatives to address chronic diseases in Aboriginal communities. It also provides an ideal platform on which to establish committed engagement and partnerships with service providers within health and social networks to improve health outcomes for Aboriginal people.


It is important to note that the most significant difference of this model from other models of care is 'trust'. Historically Aboriginal people have suffered significant losses which include not only their family but also their land, identity, language and culture to name a few. As a result many Aboriginal people do not trust mainstream health services.


To effectively apply this model to suit an Aboriginal person or community, health care workers need to have a certain skill set to develop trust from the Aboriginal person or community. These skills are not always derived from a qualification gained from higher studies but in part by taking the time to meet on Aboriginal people's terms; listening and being respectful.


The implementation plan of this model of care is currently being developed by the Centre for Aboriginal Health with the CCAP Team.

48 Hour Follow Up

The follow up of Aboriginal chronic disease patients post hospital discharge was a recommendation from the Walgan Tilly Redesign Diagnostic Report. 48 hour follow up is a Key Performance Indicator for the Chronic Care for Aboriginal People (CCAP) Program and is a monitoring measure in the Performance Management Framework.

It has been over twelve months since 48 hour follow up implementation across the State. Follow up is operational in all Area Health Services in over 45 facilities across the State, with further sites continuing to implement and refine their processes. An evaluation of 48 hour follow up is currently underway.


The objective of 48 hour follow up

To improve the health outcomes of Aboriginal patients with chronic disease, by providing follow up within 48 hours or 2 working days of discharge from an acute facility. This is to ensure appropriate links to GPs, Aboriginal Medical Services, Specialists, or other services to provide care post discharge. Follow-up covers issues such as:

  • medications (knowledge of and access to)
  • referrals (booked and transport arranged)
  • general wellbeing


In scope for 48 hour follow up.

Admitted Aboriginal patients aged 15 years and older with a chronic disease based on ICD-10 codes

The minimum requirement of a follow up.

Phone call to the patient, with at least three separate calls at different times of the day made, before patient deemed 'uncontactable'.


Resources for 48 hour followup

Toolkit 1

Frequently asked questions (PDF)

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This web page is managed and authorised by Chronic Disease Management Office of the NSW Department of Health. Last updated: 9 May, 2012