Murr-roo-ma Dhun-barn 'To Make Strong'

Justice Health & Forensic Mental Health Network, Aboriginal Chronic Care Program

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Innovation in Chronic Care

This program aims to reduce the level and impact of chronic 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 & Forensic Mental Health Network is presently the leading Area Health Service for chronic care services for Aboriginal and Torres Strait Islander peoples in NSW. As a state wide service provider for Aboriginal people 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 operationally managed by the Primary and Women's Health stream within Justice Health, with an Aboriginal coordinator leading the program. 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) state wide. The model of care consists of Justice Health & Forensic Mental Health Network 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 team provides ongoing support to all ACCP sites through for example sites visits, from the coordinator, 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 patients 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.

Rationale for the program

  • 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.

Key performance indicators

The NSW Ministry of Health, in partnership with Justice Health & Forensic Mental Health Network, have set Key Performance Indicators and these are reported on each month:

  • Spirometry
  • Hypertension
  • HbA1c
  • Urine Screening
  • Renal Disease
  • Number of Aboriginal patients accessing the program
  • Number of Chronic Conditions identified
  • Number of referrals to Care Navigation Support Team

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

Through the ACCP Justice Health & Forensic Mental Health Network 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. 

Development of the program

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.

Justice Health & Forensic Mental Health Network 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 & Forensic Mental Health Network, Aboriginal Community Controlled Health Services (NSW and ACT) and NSW Local Health Districts.

Justice Health & Forensic Mental Health Network 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.

From June 2010 The Care Navigation Support Program was implemented across Justice Health. The aim of the program , is to ensure a smooth patient journey from entry to exit from the custodial system and thereafter, through case management and shared care, both within and outside Justice Health. This provides a close working relationship between the ACCP and the Care Navigation Team, to facilitate continuum of care for Aboriginal patients, who are in contact with the criminal justice system. 


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 ill Health
  • Blood borne viruses
  • Obesity

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.

Impact of the program on the target group

The Justice Health & Forensic Mental Health Network 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.

High morbidity within the Aboriginal population in custody

% current smoker (#) 83 72
% like to quit smoking 89 85
Age first started smoking (#) 13.4 years 14.1 years
% asthma 32 27
% diabetes (#) 7 3
% heart problems 31 27
% high blood pressure 18 15

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

Less likely to seek healthcare in the community

% access Aboriginal health services in community 57 N/A
% ever been to hospital (#) 47 60
% ever been to community health centre 26 24
% ever been to GP (#) 43 71
% ever been to medical centre 43 43
% accessed no health services outside prison (#) 23 12

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


Coordinator of Aboriginal Chronic Care Program, Primary Health
Justice Health & Forensic Mental Health Network
Cessnock Correctional Centre
Phone: 02 4993 2374


Date created: 19th Jun 2009 | Date reviewed: 28th Jan 2015