Background:

Central Australia has a high burden of chronic disease. Through ‘Closing the Gap’ funding, nursing positions have been funded in Alice Springs, targeted at providing a care coordination model for Aboriginal and Torres Strait Islander people living with one or more of the target chronic conditions; diabetes, cancer, cardiac, respiratory and renal disease. Another consideration is how the social determinants of health are almost always prioritised by clients above health care and the various requirements employed to access it.

Methods:

The Tangentyere Chronic Disease Care Coordinator and Alice Springs Hospital (ASH) Clinical Nurse Consultant for Preventable Chronic Disease will present two case studies to demonstrate some of the challenges of working in partnership with people to address their social determinants of health and facilitate engagement with health services. The case studies will also highlight the opportunities provided such as fewer hospital presentations and the potential improvement in health status. The model of care to be discussed is new to Alice Springs and raises many interesting issues relevant to healthcare professionals working with vulnerable populations.

Results/Discussions:

These two positions have worked closely together to provide an individualised chronic disease care coordination service to indigenous people, supporting them to engage with inpatient treatment and access primary health care. The model focuses on working in partnership with people to address the social determinants such as housing, financial issues, poverty, food security, literacy, education, transport and domestic violence, in order for health care issues to become prioritised and self-management support to be provided.

Conclusions/implications:

The case studies demonstrate that although the level of self-management support required is often intensive, with support to address the social determinants of health, people have more opportunity to engage in their healthcare and benefit from treatment.