Table 3 Examples of strategies and actions implemented by participating community health centres to improve services and systems

▪ Dedicated new Medicare officer time to process Medicare claims

▪ Prepared for the Australian General Practice Accreditation Limited (AGPAL) accreditation

▪ Secured financial resources to fund a new nurse position

▪ Lobbied to recruit a program coordinator to coordinate chronic illness care

▪ Developed a business plan including specific chronic illness care goals

▪ Increased support from the regional Quality Improvement Coordinator to implement quality plans

▪ Increased efficiency in claiming for Medicare funded items, with funds then used to support operation and maintenance of the computerised information system

External linkages

▪ In conjunction with schools, Women's Centres, community stores or takeaways, ran chronic disease prevention programs

▪ Held regular meetings with new formed health advisory committee of Aboriginal elders, facilitating community input into health centre operation. The committee was also consulted to provide leadership and direction of community-based health activities

▪ Funded new community development positions with the health centre assisting with networking in the community and working on prevention

▪ Supported community-based initiatives, such as 'Water Aerobics'

▪ Assisted visiting nutritionist in organising the healthy lunch program in the community, and meal design and preparation for the Aged Care Centre

▪ Designated health centre time for community work on Friday am

▪ Organised an event titled "No Drug, No Violence, No Alcohol " in the community, and offered incentives, such as a return airfare to Darwin (donated by Qantas), to promote behaviour changes

▪ Ran a Diabetes Health Day in the community to improve clients' understanding of their conditions

▪ Supported the Nutrition Worker based at the community store to provide healthy foods

▪ Identified and established a list of outside services, names, and contact numbers to assist all staff to contact services and to help patients use them

Self-management support

▪ Designated chronic disease nurses to provide self-management support

▪ Implemented written care plans which contained patient goals agreed between clinicians and patients. These goals were reviewed during each visit

▪ Developed key local language concepts

▪ Arranged visiting mental health team (4 times/year) to assist with behaviour change interventions

▪ Helped setting up a Diabetes Action group in the community

▪ Designed oral guidelines and pictures to disseminate self-management knowledge and skills

▪ Enhanced smoking cessation services supported by pharmacy and availability of patches for nicotine replacement treatment

▪ Addressed concerns of patients and families through existing peer support groups at the Women's Centre in the community

▪ Provided diabetes patients with blood glucose self-monitoring materials

▪ Showed patients a food box (designed by a nutritionist) as an education tool to support individuals and families about what type of food is good for managing chronic disease

▪ Organised patient peer groups to share their stories about care, for example, buying a scrubbing brush to clean feet, rubbing feet with cream, wearing shoes, and buying good tucker from the store

▪ Supplied sharps containers for insulin dependent patients to safely dispose of needles

▪ Educated patients on general safe storage of medications

▪ Organised patient eduction delivered by the visiting Diabetes Educator from the Healthy Living NT

Decision support

▪ Provided training for primary care team by visiting specialists (eg physicians)

▪ Developed chronic disease flow sheet based on clinical guidelines (the CARPA)

Delivery system design

▪ Organised chronic disease days with presence of specialist providers

▪ Designated chronic disease nurses to implement planned visits and group visits, eg facilitating patients seeing multiple providers in a single visit

▪ Developed and implemented cross culture education and training programs for staff

▪ Held regular team meetings to revise and reinforce team roles

▪ Used registers to identify active and non-active participation of patients, analysed reasons for non-active participation, and took measures to improve

▪ When the doctor was visiting, Aboriginal health workers went out and talked to patients, and brought them into the health centre

▪ Put a sign up at the community shop for doctor's and physician's visits, and picked up people if necessary

▪ Arranged for patients to see specialists (eg ophthalmologists) in the regional centre, and transported them to their appointments

▪ Utilised interpreters provided by the Aboriginal Resource and Development Services

▪ Went out twice a day to give medications to patients in the community

▪ The health team met regularly every morning to do handover and assign responsibility for patient follow-up

▪ Commenced the use of case conferencing for patients with complex conditions and to assign responsibilities to PHC team members

▪ One afternoon a week was set aside to do home visits for patients with major chronic conditions, and documenting relevant information in the medical records

▪ Appointed the Health Centre Coordinator as team leader to ensure roles and responsibilities in chronic illness care

Clinical information systems

▪ Implemented a new electronic system (based on File Maker Pro) for recording of services, follow-up and reminding

▪ Performed a complete history notes audit and reorganised all individual files

▪ Installed a new computerised clinical information system, providing functions such as medical record-keeping, intelligent recalls, and featured appointments

▪ Developed and utilised a spreadsheet system with a list of people for follow-ups of 3 monthly bloods and the doctor's follow-ups of any abnormal findings

▪ Linked the health centre information system ("Communicare") with the regional information system "HealthConnect" to realise transfer of information between settings and community health centres