National Aboriginal and Torres Strait Islander Health Plan 2013–2023

Appendix E: Case Studies

Page last updated: 27 June 2013

The following case studies demonstrate examples of good practice and highlight the excellent work being done which is improving the health and wellbeing of Aboriginal and Torres Strait Islander people.

Innovation and Evidence Based Service Delivery Model—Institute for Urban Indigenous Health, South East Queensland
Institute for Urban Indigenous Health (IUIH). Current member Community Controlled Health Services of the IUIH are: ATSICHS Brisbane (including IUIH Moreton ATSICHS); Kambu Health Service; Kalwun Health Service and; Yulu-Burri-Ba.

IUIH has developed an evidence-based Model of Chronic Disease Care (the Model) for implementation across the Aboriginal and Torres Strait Islander community controlled health organisations in south east Queensland.

The Model aims to ensure a comprehensive patient journey for Aboriginal and Torres Strait Islander clients accessing primary health care services. It is a ‘wrap around’ model of care that is patient centric and includes Closing the Gap initiatives, and other services funded through Indigenous-specific and mainstream programs.

To make the Model evidence-based the IUIH uses detailed Aboriginal and Torres Strait Islander population counts. A key principle of the IUIH Model is that Indigenous-specific funding is used to supplement Medicare Benefits Schedule (MBS)-funded services, providing the additional preventative and primary care elements necessary to address a population with a high burden of chronic disease.

The IUIH currently supports 13 clinics (with two more proposed) across four member organisations: ATSICHS Brisbane (including IUIH Moreton ATSICHS); Kambu Medical Centre; Kalwun Health Service and Yulu-Burri-Ba. Although full implementation of the Model is in its early days, there is strong evidence that improved outcomes are being achieved.


Newly Created Permanent Aged Care Jobs and Training Achievements of Aboriginal and Torres Strait Islander Aged Care Workers at Imabulk Aged Care Services—Belyuen Northern Territory
Imabulk Aged Care service—Belyuen, Northern Territory.

Three aged care workers, Shirley, Catherine and Elizabeth have achieved Certificate III in Home and Community Care and are now completing Certificate III in Aged Care. Trudi Mardi will receive Certificate III in Home and Community Care early next year.

HK Training & Consultancy is the training organisation that has provided aged care training to Aboriginal and Torres Strait Islander aged care workers at the service since 2010. Imabulk Aged Care provides Home and Community Care and Community Aged Care Packages to 18 clients and three clients live at the centre in supported accommodation.

In 2009 three permanent part-time jobs in aged care were created under the Northern Territory Jobs Package and HK Training and Consultancy has been delivering training to the staff in these positions and other staff at the service through funding from the Northern Territory Aboriginal and Torres Strait Islander Aged Care Training Project since 2010. Staffing is very stable and there are close family links between the staff at the service.

The training and mentor support has become such a part of their jobs the staff have said “now we have done so much training I can see how it all joins together. Everything we have learnt helps us do our job better, so our old people are better looked after... Sometimes it is a case of you don’t know what you don’t know. What a difference regular training and mentor support makes!”

Two staff Catherine and Shirley completed the Certificate III in Home and Community Care in 2011 and a third staff member, Elizabeth Mardi completed in 2013; this is a great achievement for them and a great boost to the community. They continue to do training and are now enrolled in Certificate III Aged Care. The other staff are at various stages of completion of the Certificate III in Home and Community Care.

While the achievement of getting a nationally recognised qualification is undoubtedly significant, other outcomes are also impressive. The Imabulk staff love training and actively participate in all sessions. The training, while complying with the VET Quality Framework requirements, is tailored at the specific learning needs of the staff and has included a number of off-site visits.
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Integrated and Coordinated Health Care—A Patient’s Journey
Western NSW Medicare Local

A 42 year old Aboriginal man, with sleep apnoea, diabetes, post-traumatic stress disorder, and Ischemic Heart Disease was referred to the Closing the Gap - Care Coordination and Supplementary Services (CCSS) Program. The Care Coordinator was able to arrange an appointment with a respiratory physician and continued care with mental health professionals. By leveraging linkages with the Closing the Gap – Medical Specialist Outreach Assistance Program and Indigenous Chronic Disease program, which provides funding for outreach services delivered by multidisciplinary teams, the Care Coordinator was also able to access, at the one centre, all the providers needed for the patient’s diabetes care. This included an optometrist, dietician, diabetes educator, podiatrist and endocrinologist.

Throughout this process the Medicare Local regularly engaged with the local Aboriginal and Torres Strait Islander community controlled health organisations, primarily the Orange Aboriginal Medical Service.

The patient has indicated that this integrated and coordinated delivery of health care has changed his life. He has joined a gym and is well enough to have his first holiday in 20 years.


From community crisis to community control in the Fitzroy Valley: The Marulu* Foetal Alcohol Spectrum Disorders (FASD) Strategy: Making FASD history in remote Aboriginal communities.
Fitzroy Valley communities, local organisations: Marninwarntikura Women’s Resource Centre and Nindilingarri Cultural Health Service

Communities in the remote Fitzroy Valley of Western Australia’s Kimberley region have shown great leadership in overcoming FASD. In 2007, Fitzroy Valley community leaders decided to address increasing violence and dysfunction in their communities caused by alcohol abuse. The community fought to introduce local alcohol restrictions that generated positive health and social results. Furthermore, community elders recognised that drinking during pregnancy was leading to children born with FASD. The subsequent severe learning and behavioural difficulties in affected children threatened the continuation of their culture. Since 2008, led by Nindilingarri Cultural Health Services and Marninwarntikura Women’s Resource Centre, the communities have progressed the Marulu strategy with strong local, national and international partnerships.

The Fitzroy Valley communities initiated prevention strategies including local alcohol restrictions, education campaigns and support for pregnant mothers. In partnership with The George Institute for Global Health and Sydney University, from 2009-2012 they conducted The Lililwan Project, Australia’s first FASD prevalence study. This study reports among the highest rates of FASD worldwide. Yet there is hope in the Fitzroy Valley: by evaluating elements of effective prevention strategies and implementing these, FASD could be considered ‘something that used to happen’. In planning the Marulu Strategy 2013-2017, the comprehensive strategies around prevention, diagnosis and management will be progressed and evaluated through the community’s partnerships, including with the Telethon Institute for Child Health Research, WA.

This work has been featured in the 2010 Australian Social Justice Commissioner’s Annual Report, presented at the United Nations Permanent Forum on Indigenous Peoples in 2011 and 2012, directly supported by the Governor General of Australia and commended by an Australian Government Inquiry into FASD. Crucially, the strategy used in the Fitzroy Valley is represented in a National FASD Action Plan presented to Government in 2013.

*Marulu relates to children, and means ‘precious, worth nurturing’ in the Bunuba language.

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Build it and They Will Come: Outcomes From a Successful Cardiac Rehabilitation Program at an Aboriginal and Torres Strait Islander Community Controlled Health Organisation.
‘Heart Health—for our people, by our people’
National Heart Foundation
Royal Perth Hospital (Cardiology Department)
Derbarl Yerrigan Health Service and the broader Aboriginal and Torres Strait Islander community.


Cardiovascular disease (CVD) is the leading disease burden in Aboriginal Australians, but culturally appropriate cardiac rehabilitation programs are lacking. To help address this service gap, a cardiac rehabilitation program was jointly established by the National Heart Foundation, Derbarl Yerrigan Health Service (DYHS) and the Royal Perth Hospital (Cardiology Department) in DYHS (an Aboriginal and Torres Strait Islander community controlled health organisation) and its uptake, impact on health management and cardiovascular risk factors were documented.

The program was conducted onsite to provide a culturally secure environment for the provision of exercise and education to address cardiovascular health. The name of the program, ‘Heart Health – for our people, by our people’ (Heart Health) reflected ownership by DYHS and the broader Aboriginal and Torres Strait Islander community. Participants enrolling in Heart Health were invited to take part in a formal research project to evaluate the program.

Participants’ perceptions of the program and the impact on risk factors were evaluated following 8 weeks of attendance. In twenty-eight participants (20 females) who completed 8 weeks of sessions, body mass index, waist girth and blood pressure decreased and 6-min walk distance increased. ‘Yarning’ helped identify and address a range of chronic health issues including medication compliance, risk factor review and chest pain management. The evaluation concluded that the program led to improved cardiovascular risk factors and health management and an Aboriginal and Torres Strait Islander community controlled health organisation is an ideal location for managing cardiovascular health and provides a setting conducive to addressing a broad range of chronic conditions.
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