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This program aims to reduce the level and impact of preventable health conditions and promote better health for Aboriginal people and communities.

Aboriginal and Torres Strait Islander peoples that are in custody compile many Aboriginal communities with the exception that they are not the minority 2% population of the wider community but rather the majority population, representing 22% of all offenders in NSW.

Justice Health Statewide Service is presently the leading Area Health Service for chronic care services for Aboriginal and Torres Strait Islander peoples in NSW. As a statewide service provider for Aboriginal peoples in custody, Justice Health has demonstrated vision and authentic action to improving the health of Aboriginal patients through the establishment and building of the Justice Health Aboriginal Chronic Care Program (ACCP) 'Murr-roo-ma Dhun-barn' (Worimi language for To Make Strong).

The ACCP is a positive and culturally effective approach to 'Close the Gap' in chronic conditions for Aboriginal peoples who are in contact with the criminal justice system. The ACCP targets the most significant and treatable chronic conditions for Aboriginal peoples relating to cardiovascular disease, kidney disease, diabetes, chronic respiratory disease, cancer and the most at risk lifestyle factor of smoking. Targeting these avoidable and preventable diseases along with the elimination or control of tobacco use will have the most benefits to closing the gap with high mortality and morbidity rates for the Aboriginal population.

The ACCP is strategically governed and operationally managed by the Aboriginal Health team and is a good example of Aboriginal self determination and culturally informed leadership. The team has developed its own governance solutions to not be just recipients of change but leaders in change to address the existing health disparities between Aboriginal and non Aboriginal peoples in custody.

Murr-roo-ma Dhun-barn is operational in sixteen (16) correctional facilities (14 adult and 2 juvenile) statewide. The model of care consists of Justice Health nursing professionals and Aboriginal Health Workers from partnering Aboriginal Community Controlled Health Services. Working together as a primary healthcare team, they screen and provide treatment and support services for the patient so that they can learn to be self managing of their chronic condition.

The ACCP has an all Aboriginal workforce, consisting of a Coordinator fulltime, a Coordinator Aboriginal Renal / Health Promotion responsible for the renal and health promotion (tobacco control) components and an Aboriginal Health Worker educating patients on chronic care. The ACCP team provides ongoing support to all ACCP sites through for example sites visits, teleconferences, annual forums, attendance at chronic care conferences and resource materials and does not focus on individual outcomes but on the collective efforts of the designated sites to build positive outcomes.

The ACCP strategically operates in correctional sites that have significant numbers of incarcerated Aboriginal peoples so that a larger proportion of the Aboriginal population, that is 48%males, 89% females and 31% young Aboriginal males are able to access this innovative approach to chronic care services.

The ACCP has a long history of demonstrated momentum. Commencing in 2001 as a pilot project for the NSW Aboriginal Vascular Health Program, it was initially trialled in three (3) adult sites. In the next 12 months it was expanded to eight (8) sites as the Program was seen to be culturally safe for Aboriginal peoples and hence effective with addressing the access barriers faced by Aboriginal patients detained in such a complex and unnatural environment. More recently in 2008 the Program was rolled out to sixteen (16) sites, made possible by pooling funding sources, with two (2) sites being juvenile detention centres and targeting Aboriginal young people.

The main aim of the ACCP is on the early detection and intervention for chronic conditions in n Aboriginal people and through the treatment of the patient and not just the condition. This covers:

1. Systematic screening and follow up
2. Health education related to oral health, disease prevention, physical activity
3. Health promotion related to tobacco control
4. Strategies for chronic condition self management

Murr-roo-ma Dhun-barn is a comprehensive approach to addressing the chronic conditions of our of Aboriginal patients, with a focus on the whole person rather than having a single disease or 'body part' approach to health care programs and service delivery.

• The framework of the ACCP provides a practical, evidence-based and flexible approach to the prevention and management of chronic conditions in Aboriginal peoples who come into contact with the criminal justice system.
• It sets standards of care and key performance indicators against which progress can be measured.
• Even though the present incarceration rate for Aboriginal peoples is at an appalling level, many Aboriginal people use their ‘prison time’ to access the Justice Health Centres for screening, education, health promotion services and other programs to address major chronic health conditions.
• The age specific imprisonment rates for Aboriginal people are predominantly 20 – 43 years of age therefore, younger Aboriginal people are being screened for and identified with chronic conditions that are both treatable and manageable.

To 'Close the Gap' in chronic conditions for Aboriginal and Torres Strait Islander peoples who come into contact with the criminal justice system in NSW.

• To facilitate increased access to screening for early detection of chronic conditions for Aboriginal & Torres Strait Islander peoples.
• To implement individual management plans and support for Aboriginal people who have or are at risk of developing a chronic condition.
• Patients who are flagged 'at risk' are documented on the individual health assessment for further review and follow-up by the appropriate health care provider.

As a result of Murr-roo-ma Dhun-barn 52% of Aboriginal adults (Males: 48%; Females 89%) and 31% of Aboriginal young peoples (males) have increased access to targeted chronic care services.  For the reporting period July – December 2008, a total of 342 chronic care assessments were completed and 100 Aboriginal patients were diagnosed with a chronic condition. For the last quarterly period, there were 176 assessments completed. This is significant because the holiday period was also at this time.

The NSW Health Chronic Care for Aboriginal People Program (including Walgan Tilly) is in the process of setting Key Performance Indicators for Area Health Services. Justice Health has been collecting the clinical indicators that are being proposed by NSW Health relating to Blood Pressure, Spirometry, HbA1c (Diabetes) for a number of years and more recently has included Albumin Creatinine ratio to determine early stage renal disease.

NSW Health places a strong emphasis on collaboration between NSW Area Health Services and Aboriginal Community Controlled Health Services. Justice Health has working relationships with five (5) Aboriginal Medical Services providing services through the ACCP to 8 adult facilities state-wide.

National and state Aboriginal Health Framework Agreements determine for mainstream health services to provide enhanced access for Aboriginal people, which reflect their higher level of need and health care services, Through the ACCP, Justice Health has realigned the work of mainstream health professionals in nursing to better meet the need of 52% of the Aboriginal patient population. The ACCP forms part of several strategies being implemented within Justice Health to increase Aboriginal peoples accessing mainstream health facilities and services.

The ACCP relates directly to strategic directions of the NSW State Health Plan Towards 2010, specifically relating to the expansion of programs for Aboriginal people to prevent and reduce the impact of chronic disease through a focus on the common risk factors and to promote healthy lifestyles.

The percentage of Aboriginal peoples in custody has rapidly increased in the ten (10) years from 1996 – 2007 from 12% to 20% for Aboriginal males and 15% to 30% for Aboriginal females. The Justice Health, Centre for Health Research in Criminal Justice, is near completion of comprehensive research with the 2008 Inmate Health Survey. The Inmate Health Survey was last published in 2003 and both surveys have determined high morbidity related to chronic conditions within the Aboriginal population in custody. Compared to non Aboriginal people, statistics relating to the current smoking rates, age when first starting smoking, numbers wanting to quit smoking, asthma, diabetes, heart problems and high blood pressure were significantly higher for Aboriginal patients. The Surveys also highlighted that Aboriginal patients were less likely to access Aboriginal health services in the community and outside of a prison, be a hospital patient, attend a community health centre or visit a General Practitioner or Medical Centre.

Justice Health has a duty of care to provide clinically effective and culturally safe health services to Aboriginal and Torres Strait Islander peoples within the criminal justice system, which includes custody in NSW Correctional Centres and Juvenile Justice Detention Centres. To ensure that Aboriginal peoples have full access to a range of health services during their incarceration, existing health care services are drawn from the mainstream Health Centres located within the correctional facilities and enhanced health care services and programs are provided through collaborative partnerships between Justice Health, Aboriginal Community Controlled Health Services (NSW and ACT) and NSW Area Health Services.

Justice Health has a strong and functional relationship with the Aboriginal Health & Medical Research Council of NSW (AH&MRC), the peak body of more than sixty (60) Aboriginal Community Controlled Health Services (ACCHSs) throughout the state. A Partnership Agreement was resigned between the two parties in December 2008, which reaffirmed a commitment of working collaboratively together to make services happen.

Ensuring appropriate intervention and increasing access to care through firstly, dedicated health care services and secondly, with continuum of care planning, assists in reducing the disparity in health status between Aboriginal and non Aboriginal populations in the NSW adult and juvenile correctional environment.

Implementation of the Justice Health Aboriginal Chronic Care Program is directly related to the NSW Aboriginal Chronic Conditions Area Health Service Standards (2005) that promote a greater emphasis on the detection and management of chronic conditions related to cardiovascular disease, diabetes, kidney disease, chronic respiratory disease and cancer for Aboriginal people.

The project consists of small primary health teams, consisting of Aboriginal Health Workers from the local Aboriginal Community Controlled Medical Services, and Justice Health nursing professionals who together provide screening, risk assessment, referral and follow up for those who have or are at  risk of chronic disease.

Aboriginal Chronic Care Program sites in NSW

• Tamworth Correctional Centre (48% Aboriginal population)
• Grafton Correctional Centre (39%)
• Wellington Correctional Centre (48%)
• Silverwater Women’s Correctional Centre (30%)
• Cessnock Correctional Centre (30%)
• Kirkconnell Correctional Centre (12%)
• Lithgow Correctional Centre (16%)
• Mid North Coast Correctional Centre (32%)
• John Morony Correctional Centre (19%)
• Dillwynia Correctional Centre (21%)
• Broken Hill Correctional Centre (68%)
• Ivanhoe Correctional Centre (85%)
• Glen Innes Correctional Centre (32%)
• Emu Plains Correctional Centre (38%)
• Frank Baxter Juvenile Detention Centre (41%)
• Kariong Juvenile Detention Centre (51%)

The ACCP has developed a database specific to the collection of statistics that measure and monitor the progress being made in the Program on a monthly basis. .
Measures include health interventions, genetic risk factors; health promotion, referrals and monitoring by using a client register and recall system. These are used to identify what health conditions should be prioritised.

Health conditions identified are:

• Diabetes
• High Cholesterol
• High Blood Pressure
• Heart Disease
• Renal Disease
• Respiratory Disease
• Mental Health and Wellbeing Issues

The data base is used as a tool to ensure that Aboriginal patients who are identified with or at risk of a chronic condition are managed and supported in a culturally sensitive way.

The Justice Health Aboriginal Chronic Care Program reaffirms the importance of the NSW Health system to have flexibility with the delivery of health care services to Aboriginal people, families and communities in NSW. Aboriginal peoples in custody, having lower life expectancies, higher rates of chronic and preventable illness, poorer self esteem and a higher likelihood of hospitalisation are most in need of having a Program that is both culturally and community specific.  The ACCP addresses the basic human right of social inclusion by weighting to the needs of Aboriginal patients in care and giving people equal access to services to address Aboriginal health inequality.

The Aboriginal Chronic Care Program is a workable, sustainable initiative that has the framework and infrastructure to be rolled out statewide to all correctional facilities and juvenile detention centres By doing so, Justice Health can further progress towards improving chronic conditions for Aboriginal patients and become a national leader in chronic care services to Aboriginal peoples in custody.

High morbidity within the Aboriginal population in custody

2008 Inmate Health Survey
# Statistically significant (between Aboriginal/non-Aboriginal)

Less likely to seek healthcare in the community

2008 Inmate Health Survey
# Statistically significant (between Aboriginal/non-Aboriginal)

Manager, Aboriginal Health, Justice Health
Phone: 02 4993 2337