Chronic Care Aboriginal People Program

In June 2008 NSW Health launched a new direction of Chronic Care for Aboriginal People programs and initiatives. This was driven by a number of recommendations resulting from the Redesign Project Walgan Tilly.

This means that all existing and new initiatives designed for Aboriginal people with a chronic disease are now under the strategic program direction of Chronic Care for Aboriginal People - CCAP. This portfolio is managed and monitored by the Health Service Performance Improvement Branch with a Memorandum of Understanding with the Centre for Aboriginal Health.

The former programs

• Aboriginal Vascular Health Program (AVHP)
• Aboriginal Renovascular Program
• Aboriginal Chronic Care Area Health Service Standards (ACCAHSS)

Now collectively form the Chronic Care for Aboriginal People Program as does the associated funding allocated to these programs.

This is to advise you of the revised reporting arrangements for these programs. The 6-monthly State Key Performance Indicators for AVHP and ACCAHSS are no longer required to be submitted as of June 2008.

The new reporting required is in line with the Key Performance Indicators as outlined in the 2008-2009 Sustainable Access Plans including local Key Performance Indicators negotiated as part of the Walgan Tilly Project. These reports are submitted to each Executive Sponsor and Chief Executive as negotiated at the Area Health Service Level. This is then monitored by the Department monthly via SAP. Financial Reporting will also be required for CCAP initiatives commencing in June 2009.

We are also in the process of developing a framework for the development of Clinical Key Performance Indicators. These will include Blood Pressure, Spirometry, HbA1c and Albumin Creatinine Ratio, however the framework for this collection is still being

This is a significant shift in direction and reporting for this program and may require revisiting funding and activities as they relate to improved health outcomes for Aboriginal people with or at risk of a Chronic Disease. 

The Chronic Care for Aboriginal People project was named Walgan Tilly. Walgan is a Kamilaroi word meaning 'Aunty', a title of respect to Aboriginal women and 'Tilly' is short for the name Matilda.

Bronwyn Bancroft created the CCAP logo which symbolises a holistic approach to health. The focus is not just on the patient but on the family. The colours in the logo represent the connection to country.

The Walgan Tilly project interviewed and surveyed many Aboriginal patients, carers, staff and community representatives. Many issues were discovered and solutions have been identified to overcome these issues.

There are 6 state-wide solutions as listed below:

State-wide Walgan Tilly Solutions:

1. Model of Care for Aboriginal people
2. Integration of Aboriginal Health and mainstream chronic care
3. Greater Aboriginal cultural awareness and cultural sensitivity of services
4. Justice Health linkages
5. Improved access to primary care
6. Improved data quality.

There are over 20 solutions being undertaken by the Area Health Services. These are listed in the attached powerpoint slide.