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Sugar S.N.A.P – Supporting the Needs of Aboriginal People

Project Added:
20 April 2015
Last updated:
22 April 2015

Sugar S.N.A.P. - Supporting the Needs of Aboriginal People

Dubbo Diabetes Integrated Care Project


This project works across sectors to ensure an integrated approach to the care of Aboriginal people with diabetes. Fundamental to this approach is giving Aboriginal people an authentic voice in the way care is delivered to them. 

Poster from the Centre for Healthcare Redesign graduation, April 2015  Poster from the Centre for Healthcare Redesign graduation, April 2015.


To reduce the impact of diabetes on Aboriginal people in Dubbo by working with patients and partners across all services.


  • Improved health outcomes for Aboriginal people with type 2 diabetes.
  • Improved patient journey and better integration of services.
  • Reduced cost to the health care system through better management of patients in primary care.

Project Status

Project status: Implementation - the initiative is currently being implemented.

Project started:  April 2014 


Diabetes is the world’s fastest growing disease and the sixth leading cause of death in Australia. It affects 8% of the adult population of NSW, with 77% of cases diagnosed as type 2 diabetes. Diabetes is three times more common among Aboriginal people than other Australians. Aboriginal people with diabetes have a life expectancy of 17 years less than other Australians. It is estimated that 10-30% of Aboriginal people may have diabetes, with around half of these people currently undiagnosed.

In 2013, Western NSW Local Health District, Western Medicare Local and Bila Muuji Incorporated agreed to work together to improve the health of Aboriginal people in Western NSW. Dubbo has the highest Aboriginal population and was chosen as the pilot site for the project. Diabetes was identified as one of the most significant health issue affecting the Aboriginal population, requiring a high degree of coordination between service providers.

The timing of the project also aligned with the re-establishment of the Dubbo Aboriginal Medical Service and presented an opportunity to develop a relationship with the service, to improve access to care and best practice for Aboriginal people with diabetes.

The project is one of the early priorities of the Western NSW Integrated Care Strategy.


  • Work alongside the general practices in Dubbo to improve their understanding of practice data and the health of patients with diabetes.
  • Monitor and track improvements in general practitioner care and provide evidence-based diabetes care, including the completion of the diabetes Cycle of Care (COC), in the primary care setting.
  • Develop a network for Aboriginal Health Workers in Dubbo and improve their ability to help patients manage their diabetes, with shared education, resources and teamwork across all services.
  • Develop a single, culturally appropriate pathway to care for Aboriginal people with type 2 diabetes in Dubbo.
  • Implement a shared care planning tool (cdmNet) to improve patient communication and the feedback loop.
  • Work with local health professionals to promote enrolment and identification of Aboriginal people with diabetes into the National Diabetes Services Scheme (NDSS).
  • Work with the Aboriginal Medical Service to develop a one-stop shop for integrated diabetes care. 


  • Western NSW Medicare Local
  • Dubbo Aboriginal Medical Service
  • Barwunga Aboriginal Medical Service
  • Dubbo Medical and Allied Health Service
  • The University of Sydney


The following measures are being used to evaluate the project.

  •   Development of a single locally-agreed pathway to care for Aboriginal people with type 2 diabetes in Dubbo (June 2015).
  •   Effective use of the shared care planning tool by the Aboriginal Medical Service, used across all services, with ongoing use of the feedback loop and electronic referral processes (May 2015).
  •   Improved clinician satisfaction with the shared care planning tool and communication loop (October 2015).
  •   Increased registrations of Aboriginal people from Dubbo on the NDSS by 20% (September 2015).
  •   Improved self-reported confidence of Aboriginal Health Workers in helping people manage their Type 2 diabetes (November 2015).
  •   Improved rates of completion of diabetes COC for Aboriginal people with Type 2 diabetes, from 16% to 36% (November 2015).
  •   A 20% increase in the number of Aboriginal people from Dubbo who have been identified with Type 2 diabetes (June 2016).

Lessons Learnt

  • Diabetes is a complex condition to manage and requires a large number of stakeholders to be involved in the process.
  • Ethics approval is a necessity when planning a project involving the interviewing of Aboriginal staff and patients (identified as a vulnerable group) and takes a long time to be approved.
  • The number of people with diabetes in the National Diabetes Service’s database is inconsistent with local data, and it is difficult to determine which registered patients have identified as Aboriginal in the database.
  • Clinician practices are varied in all sites and can be markedly different despite best practice guidelines for diabetes being readily available.
  • There is a great deal of confusion around local services and pathways to care.
  • The ability to integrate care depends on strong relationships between providers and this takes time to develop and strengthen.
  • Changes to funding makes integrated care projects difficult to sustain when services and providers change frequently.
  • Patient behaviour is not always well understood and generalisations can be made about why people choose certain health behaviours if the patients’ perspective is not considered.


Anne Field
Manager Performance and Service Development - Integrated Primary Care and Partnerships
Western NSW Local Health District
Phone: 0427 843 240

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