Background: The impact of type 2 diabetes is severe in Aboriginal and Torres Strait Islander people. The Fitzroy Valley, a remote region of the Kimberley in Western Australia, has a high population of Indigenous Australians. An effective community partnership has been formed between the local hospital, the population health service and local health services.
Objective: This article describes the evaluation of a new model of partnership care using an audit cycle. Results Statistically significant improvements in foot examination, body mass index, urine albumin creatinine ratio, total cholesterol, triglycerides and visual acuity measurements were observed. Significant increases in the proportion of patients achieving cholesterol and triglycerides therapeutic targets occurred. Most other outcome indicators demonstrated a nonsignificant improvement, which may be due to the short time interval in the audit for potential change.
Conclusion: A dedicated chronic disease team and a clinical information system to coordinate culturally appropriate, multidisciplinary chronic disease care enables effective management of chronic diseases such as type 2 diabetes.