Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from chronic illness such as diabetes, renal disease and cardiovascular disease. For example, the estimated prevalence of diabetes among Indigenous adults is between 10% to 30%, 2–4 times higher than that of non-Indigenous Australians . Hospitalisation rates for diabetes were 10–15 times higher when compared with the total Australian population . The death rate associated with diabetes for 35–54 year old Indigenous people was 27–35 times that of their non-Indigenous counterparts . The incidence rate of end stage renal disease for Indigenous Australians (779 per million) was 9 times the rate for non-Indigenous Australians (86 per million) . The death rate from chronic renal disease was 10 times higher for Indigenous people than for non-Indigenous people . These national statistics indicate that effective management of chronic illness among Indigenous people should be a high priority primary care service in order to slow the progression of disease and prevent or delay related complications.
While mainstream Australians access primary care through a universal system of general practice funded through Medicare , primary care systems for Indigenous people are more complex, with three major services sectors: Indigenous community controlled services, state and territory funded/operated services, and general practices . Indigenous people's access to general practice is limited, particularly in Australia's Northern Territory (NT) where 70% of its Indigenous people live in rural and remote communities where there are few GPs . Therefore, health centres located in Indigenous communities are at the forefront in providing primary health care to the majority of Indigenous people living in the NT.
Many Indigenous community health centres, whether community controlled or state and territory funded, are overwhelmed by providing 'sickness care' for people who are acutely unwell. The focus on acute care services is a result of the high rates of illness in Indigenous communities, combined with limited staff numbers and high staff turnover . While acute care is an ongoing necessity, Indigenous community health centres must at the same time provide effective care for people with chronic illness.
In an international context, the Chronic Care Model (CCM)  has gained popularity in recent years as a conceptual model for understanding systems to support chronic illness care and guiding organisational development. It has been adopted and expanded by the WHO to develop an Innovative Care for Chronic Conditions Framework for policy development and system redesign in global contexts . However, clinical training has generally not paid adequate attention to primary care systems, and systems concepts and the value of assessment of the quality of systems may not be fully appreciated by health teams.
Informed by the CCM framework and modern Continuous Quality Improvement theory , we conducted a five year quality improvement study (2002–2006), the Audit and Best-practice for Chronic Disease (ABCD) project in Indigenous community health centres in the NT, aiming to support health centre staff to improve their primary care systems for chronic illness care and preventive care. The relationship between the level of health centre system development and quality of diabetes care , and the impact of intervention on prevention and management of chronic illness have been reported elsewhere [14, 15]. In this paper we report on a practical application of the Chronic Care Model to describe the extent to which Indigenous community health centre systems support chronic illness care and to identify strengths, weaknesses, barriers, and opportunities within these systems.