Moving beyond Chronic Disease: the benefits of placing Chronic Disease Care Coordination in a non-clinical setting

Ms Annie Farthing1, Ms Marianne Cummins2

1Centre for Remote Health, Alice Springs, Australia, 2Tangentyere Council, Alice Springs, Australia


The authors are a nurse and an allied health professional who work together in an Aboriginal Community Controlled Council to provide Chronic Disease Care Coordination to Town Camp residents in Alice Springs.  Such residents are often culturally and linguistically isolated from the services available in town and remain in unacceptably low living standards.  Most of the clients involved in the program are not named on any housing lease with around 30% regularly moving between addresses or sleeping rough. No clients own a vehicle. Poor access to housing, stable and sufficient income, food and transport have contributed to the overwhelming burden of chronic disease in the Town Camp populations.

Tangentyere Council is an Aboriginal Community Controlled organisation, founded to give Aboriginal residents of Alice Springs’ Town Camps a voice.  Placing the Integrated Team Care Coordination in this organisation allows for emphasis to be placed on finding ways to address challenging social determinants; as well as supporting people with chronic diseases and their families to access clinical services provided by the Aboriginal Medical Services as well as mainstream health services

What works:

A flexible outreach service under the direction of a non- clinical Community Controlled Organisation

GPs willing to add non- clinical issues to the GP care plan

Advocacy on behalf of individuals to negotiate multiple and complex organisations

Good relationships with clients, families and services


What challenges us:

Funding an Aboriginal Outreach worker

Processes which cannot take into account the challenging circumstances of people

Organisations who discourage developing relationships


Annie has lived and worked in Central Australia for 25 years.  Most of the time Annie works at the Centre for Remote Health with undergraduate students but also enjoys getting out and doing some physio work in the community