Getting better at chronic care in remote communities: study protocol for a pragmatic cluster randomised controlled of community based management

Barbara Schmidt, Mark Wenitong, Adrian Esterman, Wendy Hoy, Leonie Segal, Sean Taylor, Cilla Preece, Alex Sticpewich, Robyn McDermott

Prevalence and incidence of diabetes and other common comorbid conditions (hypertension, coronary heart disease, renal disease and chronic lung disease) are extremely high among Indigenous Australians. Recent measures to improve quality of preventive care in Indigenous community settings, while apparently successful at increasing screening and routine check-up rates, have shown only modest or little improvements in appropriate care such as the introduction of insulin and other scaled-up drug regimens in line with evidence-based guidelines, together with support for risk factor reduction. A new strategy is required to ensure high quality integrated family-centred care is available locally, with continuity and cultural safety, by community-based care coordinators with appropriate system supports.