Background:

Aboriginal people in the Northern Territory suffer high rates of chronic disease. The CCSS program aims to improve health outcomes for Aboriginal people with chronic disease through better access to coordinated multidisciplinary primary health care.
A high proportion of the Aboriginal population live traditionally in rural and remote locations, have English as a second language, low levels of English literacy and many are disadvantaged or homeless. Many do not feel culturally safe when accessing mainstream primary health care services. This impacts on access to services and contributes to poor health equity.

Methods:

The Northern Territory Medicare Local (NTML) CCSS program recognises that health care presentations by Aboriginal people are often in the acute phase and Aboriginal Medical Services (AMS) or local health facilities are the preferred location. The NTML delivers the program in partnership with AMSs and Aboriginal community controlled organisations to ensure culturally safe care is delivered. Care Coordinators facilitate chronic disease management, follow up care and specialist referrals, considering the social determinants of health and how these impact the continuum of care for their clients.

Results/Discussions:

Since the initial round of funding in 2010-11 the program has grown by 800%, with 24 Care Coordinators across 10 organisations now servicing the NT. In 2013, significant growth was reported in the number of General Practitioners referring to Care Coordinators, the number of clients receiving care coordination services and the total episodes of care. Medicare Benefits Schedule (MBS) statistics and ICDP measures are also indicative of the success of the NTML CCSS program.

Conclusions/implications:

The benefits of a culturally appropriate and holistic approach through addressing social determinants of health are demonstrated through the NTML CCSS program. Program outcomes affirm the contribution to improving health equity and reducing the gap in life expectancy for Aboriginal people in the NT.