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KIT SMART: Improving Health Outcomes for Aboriginal People with Diabetes

Awabakal Aboriginal Primary Health Care Centre
Project Added:
8 April 2016
Last updated:
28 April 2016

KIT SMART: Improving Health Outcomes for Aboriginal People with Diabetes


A KIT SMART program was developed to improve data entry, monitoring and reminders, roles and processes, and models of care for diabetic patients at Awabakal Aboriginal Primary Health Care Centre.

KIT SMART stands for:


Total Control.

kit smart poster

View a poster from the Centre for Healthcare Redesign graduation, April 2016.


To increase the number of diabetes annual cycle of care programs completed from one to 65 and decrease the number of patients with no recording of a HbA1C test in last 12 months from 131 to 95, by 31 July 2016.


  • Educates patients so they understand the importance of regular blood sugar monitoring and can better manage their diabetes.
  • Increases access to specialist services and support in the community.
  • Develops a collaborative approach to care.
  • Reduces the number of steps in the chronic care process.
  • Ensures that chronic disease management is a core business activity for all staff.
  • Potentially reduces health complications associated with diabetes, through ongoing management and promotion of healthy lifestyle choices.


In Australia, Aboriginal people are 3-4 times more likely to have diabetes. The death rate from diabetes is six times higher than that of non-Aboriginal people, due to high levels of associated health conditions such as heart, blood and kidney diseases.

Type 2 diabetes represents a serious public health problem for Aboriginal people, with the disease occurring at a higher rate and starting at a much earlier age than non-Aboriginal people. Research shows that Type 2 diabetes accounts for 11% of new diabetes cases in Aboriginal children aged 10-18 years old, which is six times higher than non-Aboriginal children in Australia.

In July 2015, Awabakal found that only one patient had completed an annual diabetes cycle of care program in the last 12 months and 50% of diabetes patients did not have a HbA1c test in the last 12 months. The HbA1c test shows an average of the patient’s blood glucose level over the past 10-12 weeks and should be completed every 12 months.

It was determined that a new model of care was required, to improve and maintain the care provided to Aboriginal patients with diabetes.


  • A root cause analysis was conducted, which identified four areas for improvement: data entry; monitoring and reminders; roles and processes; and a clear model of care.
  • Solutions were developed, based on the Easy, Attractive, Social and Timely (EAST) Framework.
  • The Chronic Care Process Map was simplified from 11 to 7 steps. This process identifies who is responsible for the patient’s care at each stage of their journey and the outcomes that need to be achieved.
  • An incentive program was developed, to encourage staff to achieve an optimal outcome in fewer steps.
  • Clinicians, general practitioners and nursing staff were allocated as project champions, to lead the project.
  • Awabakal staff were provided with training in data entry, so information in the system reflected the status of Awabakal patients.
  • Reminder letters and phone calls to patients who were due for a HbA1c test were implemented, to help them proactively manage their diabetes.
  • A diabetes educator was recruited to engage patients in the KIT SMART program and monitor the diabetes and chronic disease registers.
  • The KIT SMART program was promoted to the local community with posters, t-shirts and information on the Awabakal website, Facebook page and email newsletter.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • Project start: 15 July 2015
  • Project launch: 19 November 2015
  • Project finish: 31 July 2016

Implementation sites

  • Awabakal Aboriginal Primary Health Care Centre, NSW
  • Karuah Outreach Clinic, NSW
  • Toronto Outreach Clinic, NSW
  • Mindaribba Outreach Clinic, NSW

Evaluation and Results

  • Awabakal is on track to achieve its aim by 31 July 2016, when a full evaluation will be completed.
  • As of April 2016, 45 diabetes annual cycles of care have been completed (target is 95).
  • As of April 2016, Awabakal has 110 diabetic patients with no recording of a HbA1c test in the last 12 months (target is 65).
  • Patient and staff surveys will be distributed in August 2016, to collect feedback on the KIT SMART program.
  • There is ongoing monitoring and collection of data, with results discussed in monthly meetings.

Chart showing data increasing toward goal and target

Data decreases toward goal getting closest Nov 2015, then increased slightly

Lessons learnt

  • The delay in recruiting a diabetes educator and the absence of the project lead affected the timeline of the project and delayed progress slightly.
  • The new Chronic Care Process Map is suitable for the management of all chronic disease, not just diabetes.
  • The program is no longer an extension of the medical service but is a core business activity for all staff.

Further reading

  • O’Dea K, Rowley K, Brown A. Diabetes in Indigenous Australians: possible ways forward. Medical Journal of Australia 2007; 186(10): 494-495.
  • Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: First Results 2012-13 (cat. no. 4727.0.55.001). Australia; 2013.
  • McDermott RA, McCulloch BG, Campbell SK et al. Diabetes in the Torres Strait Islands of Australia: better clinical systems but significant increase in weight and other risk conditions among adults, 1999–2005. Medical Journal of Australia 2007; 186(10): 505-508.
  • Diabetes Queensland


Debbie Massie
Medical Service Manager
Awabakal Aboriginal Primary Health Care Centre
Phone: 02 49 078 555

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