A local program changing the trajectory of chronic illness in First Nations people and providing greater access to care and education will be showcased across the state next month.
Mackay Hospital and Health Service nurse practitioner Maree Wearne will present the incredible successes and improved community health outcomes of the Together Strong Connected Care program at the Clinical Excellence Showcase in Brisbane.
The healthy lifestyle program is for First Nations and Australian South Sea Islander people who are at risk of type 2 diabetes, living with type 2 diabetes or have post-gestational diabetes.
The program uses group lifestyle sessions, one-on-one care management and community event education to support those at risk, newly diagnosed or living with the debilitating condition which is prevalent in these communities.
Providing diabetes education, timely access to care and sharing practical tools to manage illness and prevent further decline, all in a culturally appropriate way, was helping reduce the growing pressure on healthcare providers including general practitioners and hospitals, Maree said.
“Diabetes is a huge issue for these people. This program helps those in Mackay, Whitsunday and Isaac regions understand the risks and complications of type 2 diabetes, assists them in reducing the chances of hospitalisation, supports the management of diabetes through healthy lifestyle choices and works together with healthcare providers for type 2 management,” she said.
“It’s a way we can increase access to care for the most vulnerable, helps avoid hospital presentations and reduce admissions and offers them specific diabetes education.
“This program is a healthcare buffer – it’s adding value and access, supporting and taking the pressure off the system. It’s really a step up from primary health and step down from hospitals,” Maree said.
A lack of knowledge about the disease is a challenge but the Together Strong Connected Care program has generated a lot of interest via word-of-mouth as it offers early assessment, personal care plans, intervention management treatment, step down maintenance and monitoring with culture as a foundation.
“Many in these communities just accept diabetes as their fate as others in their family have it, but this program helps show them how, with good management and practical tools, they can change their health trajectory and stop or slow a decline into chronic illness,” she said.
“We are teaching them how to control their diabetes, not be controlled by it.”
The use of Continuous Glucose Monitors (CGMs) in the program had been “game changing”.
“CGMs give patients a visual representation of their blood sugars 24/7 and shows them how their food intake, exercise and insulin affect their blood sugars. This is a very powerful learning tool proven to support understanding and behaviour change and has reduced the acuity of diabetes and complications like kidney disease, loss of eyesight and amputation,” Maree said.
The program has just been approved for a six-month CGM trial run by the NHMRC (National Health Medical Research Centre) in collaboration with the University of Melbourne which Maree hopes will eventually ensure monitors will be subsidised.
The Together Stronger Connected Care program team consists of Indigenous community liaison officers, an outreach support officer, a credentialed diabetes educator, a virtual health support officer, nurse practitioner, physiotherapist and dietitian.
In less than 12 months, the team has received more than 100 referrals from GPs, community health care workers, hospitals as well as self-referrals, and now has about 70 active program participants.
Maree, who has more than 30 years’ experience in First Nations healthcare, said she was excited to present the benefits of the program at the Clinical Excellence Showcase next month and demonstrate how it could also be applied to programs targeting other chronic illnesses.
“It’s exciting and very motivating to see the improvement in health outcomes including achievements such as reducing obesity, cutting back on medications and patients coming off insulin because of changes we’ve helped them make,” she said.
“These kinds of results prove that the program and its practical measures and education initiatives are working.
“Health outcomes in these First Nation peoples are improving because of this program, with some achieving diabetes remission,” Maree said.
“Lives in rural and remote areas and health trajectories in these communities are ultimately being changed for the better.”
