Chronic Disease Care Coordinator


Many Central Australian Aboriginal people residing in the Alice Springs Town Camps have poor nutritional intake, low levels of physical activity, are more likely to smoke (73% of males aged 18-24 smoke) and suffer from hypertension (100% of males >65 years suffer from hypertension ). In addition there is a significant proportion of this population that is overweight or obese. Aboriginal people are 13 times more likely to suffer from diabetes, 5 times more likely to suffer from heart disease and 7 times more likely to suffer from chronic kidney disease. Mortality rates for Aboriginal people are high and life expectancy is comparatively low.

The reality for Aboriginal people is that the risk factors and the prevalence of chronic illness are in contrast to the non-Indigenous population.

Tangentyere supports the role of the Medicare Local Outreach Workers and the role of the Care Coordinator as it is the experience of Tangentyere than many Central Australian Aboriginal people don’t access primary health care until their chronic illnesses are seriously impacting upon their health.

It is the repeated experience of Tangentyere Programs that sufferers of chronic diseases who are sleeping rough or residing in overcrowded dwellings have been referred through ‘Accident and Emergency’ and ended up in a ‘Medical Ward’ only to self discharge the following day to be re-referred by Saint John Ambulance staff in the early hours of the morning. Many clients have indicated dissatisfaction with primary health providers and this has contributed to a lack of proactive engagement with these providers. Additionally many people lack time management, literacy & numeracy and the confidence to access primary health services and benefit from the additional support offered by a Care Coordinator.

Many clients have multiple chronic conditions requiring integrated care plans.

Challenges to Accessing Health Care

    1. Poor Literacy and Numeracy
    2. Limited Spoken and Written English
    3. Low Self Esteem and Confidence
    4. Lack of Transport
    5. Homelessness
    6. Alcohol and Other Drug Issues
    7. Exposure to Family Violence and Trauma


The Chronic Disease Care Coordinator is funded as part of the Commonwealth Government’s policy imperative to Close the Gap and specifically as a strategy to tackle Chronic Disease through improving the access of Aboriginal Australians to specialist, general practitioner and allied health services.

The primary objectives of this position are to deliver the following outcomes:

  • To provide all patients with an identified Chronic Disease with a care plan;
  • To accept referrals from General Practitioners;
  • To register all patients for the Practice Incentives Program (PIP) Indigenous Health Incentives;
  • To support patients to access required specialist, GP and allied health services in a timely manner;
  • To provide appropriate information to patients to improve their understanding of their illness;
  • To develop knowledge of strategies to assist in the improvement of health outcomes;
  • To support patients to engage in healthy lifestyle activities;
  • Provide a supportive environment to patients to improve self efficacy

5 Key Chronic Diseases

  • Diabetes
  • Renal Disease
  • Respiratory Diseases
  • Cancer
  • Cardiac Disease


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department info

Phone: 08 8951 4244
Fax: 08 8952 8521
Email: Click to send

4 Elder Street
Alice Springs,
NT 0870

PO Box 8070
Alice Springs,
NT 0871

Tangentyere Council