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Providing comprehensive care to Aboriginal and Torres Strait Islander peoples with chronic comorbities

How a practice maximised their patient database to provide improved healthcare to Aboriginal and Torres Strait Islanders with chronic comorbidities

Please refer to the disclaimer before reading the case studies.


A north-west Queensland practice team and a broad range of allied health providers and specialists are brokered through a subsidised scheme on a monthly roster. They have a total patient load of 5400, with 2900 active patients.
The group provided high-quality comprehensive primary healthcare with a key focus on Aboriginal and Torres Strait Islander patients that present with chronic comorbidities.
Patient information systems were incomplete and did not accurate reflect the active client load. Follow-up items of care were undertaken in an ad hoc manner without due diligence to providing comprehensive primary healthcare against cycles of care.
To ensure patients have access to the cycles of care against particular comorbidities, such as type 2 diabetes or CVD.
To maximise capacity in both the administrative and clinical team to incorporate principles of improvement, namely ensuring data quality and adequacy of patient record information.
The first step was to ensure that the data contained in the patients records was appropriately recorded (clean), and that demographic information was current and completed. Administrative and clinical staff were trained in the use of a data cleansing tool, and were tasked with ensuring data was clean and complete. This activity identified missing demographic information and prompted all clinical staff to complete clinical information for each patient being seen for the day.
Once the clinic had access to high-quality data, systematic recall processes were put in place. At weekly meetings, there was a focus on the follow-up case items suggested for chronic comorbidities. Ongoing reviews of increases in episodes of care were also discussed, and priorities were set for the following week.

  • Completed demographic information now ensures record accuracy
  • Increased identification of patients with chronic obstructive pulmonary disease (COPD), risk of CVD and type 2 diabetes
  • Smoking status is recorded on 78% of patient records for patients aged ≥ 18 years.
  • Follow-up care has increased by 45% for type 2 diabetes cycles of care.
  • Review of recall systems review has resulted in an increase of 200% in recalls.
  • Communication and role autonomy across the administrative and clinical team has been strengthened.
  • The Continuous Quality Improvement program has been added to the weekly staff agenda.
  • Local hyperosmotic hyperglycaemic syndrome (HHS) reports indicate that hospital / emergency presentations have reduced.
  • The Aboriginal community-controlled health service has positioned itself as an employer of choice.

The Aboriginal community-controlled health service has access of patient information systems that reflect their current client load and the team is committed to ongoing Continuous Quality Improvement. The team are involving all staff from when the patient walks through the doors to when they leave, maximising care and ensuring role autonomy with staff. All position descriptions have been reviewed to include QI. Performance appraisals set and measure achievements against measurable indicators. The Aboriginal community-controlled health service has included the use of the data tools in induction and orientation processes. The service has established and embedded principles to ensure ongoing improvement of the data systems that support patient care.

Ms Lauren Trask, Accreditation Specialist, Queensland Aboriginal and Islander Health Council


The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

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