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use guidelines, recall systems and care planning (62) . Specialist multi disciplinary teams to addressthe specific needs of those with chronic disease should also be a priority – diabetes educators,cardiac educators, foot care specialists for diabetics and eye specialists.3.4.2 Staffing chronic disease programsSince 2001, a total of eight Public Health Nurse positions have been created in the NorthernTerritory to enhance the capacity of remote health services to establish and manage chronicdisease programs. These positions have played a key role in training staff about chronic diseaseprevention and management and the implementation of systems to support care.In addition to the Public Health nurses an additional Chronic Kidney disease nurse was employedin the Top End in renal services in 2004, to complement a similar position that was established inCentral Australia in 1998. These positions play an important role in supporting people with kidneydisease to maintain their health and slow the transition to renal replacement therapy. In the 2007financial year, the number of chronic kidney disease nurses is expected to increase with anadditional six positions funded by the Northern Territory Government and four positions to befunded by the Australian Government located with AMSANT. These positions will be spreadacross the Northern Territory with three to be placed in Central Australia, two in the Top End,and with one full time educator position to support workforce development for renal services. Anadditional four positions will be located with AMSANT to support community controlled healthservices to support intensive management of renal clients. Finally, a further three positions willbe located with the Preventable Chronic disease team to support intensive case management ofrenal clients in remote areas.Table 3.6Positions created in the NT by year commenced and funding sourcePositionsLocationYearCommencedFunding Source1 x Renal Central Australia 1998 NTG1 x PHN Darwin 2001 NTG1 x PHNKatherine (transferred to Sunrise HS2003 as part of CCT)2001 S1001 x PHN East Arnhem 2001 S1001 x PHN Cental Australia 2001 S1001 x PHN Central Australia 2001 S100Chapter 3: Progress Against PCDS Objectives – Evaluation of the NT Preventable Chronic Disease Strategy 2007 50
1 x AHW Central Australia 2001 S1000.5 x CDC N4 Millingimbi 2001 S1000.5 x DCC N4 Ramingining 2001 S1001 x DCC N4 Oenpelli 2001 S1001 x DCC N4 Maningrida 2001 S1001 x DCC N4 Wadeye 2001 S1001 x Renal Top End 2002 Industry (Janssen-Cilag)1 x CDC N4 Groote Island 2003 S1001 x AHW4 Groote Island 2004 S1001 x PHC, N4 Ntaria 2005 PHCAP through CAAC1 x PHN, N4 Yeindemu 2005 PHCAP through CAAC1 x PHN, N4 Angininyi for Tennant Creek 2005 PHCAP through Angininyi1 x CDC N4 Tiwi Health Services 2006 NTG1 x CDC N4 Douglas Daly region, Adelaide River 2006 NTG1 x CDC N4 Boroloola 2006 NTG1 x PHN, N4 Angininyi 2006 DoHA (regional funds)I X PHC , N5 Groote Eylandt 2006 NTG1 X PHC P3 Maningrida 2007 OATSIHNEW POSITIONS JULY 20071 x PCDEducatorNT Wide 2007 NTG1 x Renal PHN Central Australia Congress 2007 OATSIH (AMSANT)1 x Renal PHN Anginyinyi, Tennant Creek 2007 OATSIH (AMSANT)1 x Renal PHN Wurliwurlijang Katherine 2007 OATSIH (AMSANT)1 x Renal PHN Danila Dilba, Darwin 2007 OATSIH (AMSANT)1 x PHN N4 Barkly 2007 NTG2 x PHN, N4 Darwin 2007 NTG2 x PHN, N4 Nhulunbuy 2007 NTG3 x PHN, N4 Central Australia (PCD team) 2007 OATSIHThe four PHCAP funded PHN positions were envisaged as having a similar role with theimprovement of clinical systems, auditing, and training. However as they have differentemployers, they have taken on a community health promotion role and a stronger focus on adulthealth checks. The PCD team and CAAC meet regularly to discuss how best to use these rolesand how to support those in them.The expanded PCD team will work more closely with a smaller number of communities toimprove disease management and provide hands on support for adult health checks. They willChapter 3: Progress Against PCDS Objectives – Evaluation of the NT Preventable Chronic Disease Strategy 2007 51
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Pty LtdABN 82 147 637 101AN EVALUAT
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TABLE OF CONTENTSList of figuresLis
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6.6 Indigenous workforce 996.7 Prev
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List of AbbreviationsABCDACCHOsACIC
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ACKNOWLEDGEMENTSWe would like to ac
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However the extraordinary number of
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the establishment of the Sunrise He
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RECOMMENDATIONSGeneral recommendati
Page 17 and 18: Exploration of joint funding arrang
Page 19 and 20: CHAPTER 1. INTRODUCTION1.1 Backgrou
Page 21 and 22: Choosing the 5 chronic conditionsTh
Page 23 and 24: Table 1.1Key Result Areas + Best Bu
Page 25 and 26: prior to the launch of NTPCDS, such
Page 27 and 28: Year * Action Outcome1999 S NT Prev
Page 29 and 30: Year * Action Outcome2005 P Aborigi
Page 31 and 32: CHAPTER 2.EVALUATION METHODOLOGYThe
Page 33 and 34: 2.2 Evaluation StagesThe NTPCDS eva
Page 35 and 36: chronic disease activities funded t
Page 37 and 38: internal project team. It was very
Page 39 and 40: Situation at Baseline1. The Guideli
Page 41 and 42: 3.1.2 Patient information and recal
Page 43 and 44: Ferret Miwatj, Numbulwar, Marngarr,
Page 45 and 46: Medicare information is not for pub
Page 47 and 48: was in place in Central Australia i
Page 49 and 50: What orientation and ongoing traini
Page 51 and 52: programs focus on chronic disease p
Page 53 and 54: The information collected as part o
Page 55 and 56: Assessment against objectiveMost se
Page 57 and 58: career development, and retention i
Page 59 and 60: are. Indigenous employment is NTDH&
Page 61 and 62: NTDH&CS Programs that encourage Hea
Page 63 and 64: 2002 Aboriginal and Torres Strait I
Page 65 and 66: delivering any prevention and healt
Page 67: The Community Services Division - A
Page 71 and 72: One clinic stated it had no care pl
Page 73 and 74: Identifies priority practices to in
Page 75 and 76: There has been a significant growth
Page 77 and 78: about 25 per cent of the hospital b
Page 79 and 80: The level of funding provided by th
Page 81 and 82: Central Australia and two zones cur
Page 83 and 84: The diabetes education teams at HLN
Page 85 and 86: maintenance group for people with l
Page 87 and 88: Rebates for participating or arrang
Page 89 and 90: Use of Medicine Programmes. Althoug
Page 91 and 92: CHAPTER 4. CLINICAL OUTCOMES OF THE
Page 93 and 94: improvements have been made to serv
Page 95 and 96: A recent ten-year follow-up of a co
Page 97 and 98: The NTDH&CS also collect birthweigh
Page 99 and 100: Figure 5.3 Vaccination coverage for
Page 101 and 102: It is also important to note that k
Page 103 and 104: eported that 50 per cent of the Ind
Page 105 and 106: The current action plan identifies
Page 107 and 108: The availability and cost of health
Page 109 and 110: Hoy et al in 1995-2000 (100) , and
Page 111 and 112: 5.6 Best practice management5.6.1 P
Page 113 and 114: disease care in urban areas regardi
Page 115 and 116: PCIS was developed by NTDH&CS as th
Page 117 and 118: emote staff can access training and
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In the Top End there appeared to be
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APPENDIX 1EVALUATION OF THE NT PREV
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2.10 Generally speaking, on a scale
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4.4 Briefly recount any anecdotes y
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5.9 Generally speaking, on a scale
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Section 8 • Summary questions8.1
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Preventable Chronic Disease Program
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Year Type Background What is it? /
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Year Type Background What is it? /
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An important background to this stu
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New beliefs do not replace the old,
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Other services are provided to the
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ecame the main priority in many peo
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to be healthy, how to get rid of di
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(Draft Version - © August 2006 Jan
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References1. Dunham, H., Ministeria
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35. Smith, J.D., Progress report fo
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Research Centre for Aboriginal Heal
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114. Senior, K., 'A Gudbala Laif? h
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