This project built on previous research around chronic condition management (CCM) in primary health care and community settings, particularly through the Centre for Clinical Research Excellence in Aboriginal Health, a partnership of Flinders and AHCSA. The aim was to demonstrate effective and sustainable CCM strategies for Aboriginal communities, and generate research evidence about the benefits, barriers and enablers of effective CCM.

Using a participatory action research approach and mixed methods, the project explored issues and contexts around the existing CCM strategies at each health service, introduced and supported additional CCM strategies (eg self management training, care plan promotion posters, peer support group) according to each service’s priorities and capabilities, and examined the health outcomes and impacts associated with CCM strategies. Capacity development opportunities were integral to the project design.

Analysis of clinical data from clients involved in structured CCM strategies (eg client-centred care planning, self-management support) showed that there were statistically significant and clinically important improvements over time in key health indicators (e.g. body mass index, cholesterol, haemoglobin A1c).

Interviews with clients confirmed the benefits of CCM strategies including:

  • New knowledge about chronic conditions and how to manage them
  • Empowerment and taking control of own health
  • Setting and achieving personal goals
  • Reassurance and keeping track of progress
  • Feeling better and avoiding complications.

The participating health services varied greatly in their approach to CCM. This project facilitated sharing of successful strategies and systems. Key enablers of effective CCM strategies were identified through interviews with staff and clients, including:

  • Access to appropriate and affordable health services
  • Effective clinical information management system
  • Coordination and team care arrangements
  • Facilitation of peer support
  • Staff capacity and training in chronic condition management
  • Engagement with clients and community
  • Encouragement and support for clients
  • Client knowledge of chronic conditions and their management
  • Commitment to lifestyle change
  • Family and peer support.

Through this action research project, staff training in chronic condition self management was provided, posters to encourage clients to get involved in care planning were developed with PLAHS, and a community support group was supported in the Riverland.

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