The Chronic Disease Program employs two health professionals, who work with the doctor ‘buddies’ as a team to encourage the prevention, early detection and coordinated management of the chronic diseases such as hypertension, diabetes, heart disease, kidney disease and others.
The goal is for the chronic disease team to act as the directors of these activities, planning and coordinating them rather than actually carrying out all the ground work themselves.
For example, the Chronic Disease AHW whose main area is diabetes will at regular intervals generate lists of DAHS patients with diabetes who are overdue for a HbA1C diabetes monitoring test. They will then notify these patients that they are overdue and offer follow-up, which might be to get a lift with the DAHS driver on a day which best suits the patient to attend the DAHS general clinic for their follow-up. Or they may choose to make an appointment for the next DAHS CDM clinic.
There are a number of Aboriginal Health Workers at DAHS who are skilled in the use of the retinal camera to screen for diabetic eye disease. Photos are taken with the camera through dilated pupils every year and pictures are then sent via secure messaging using MMEX to the ophthalmologist in Perth for analysis and comment. These photos can be done opportunistically (offering the service when a patient happens to be in the clinic for another reason, e.g. a dressing) or in a targeted way (diabetes worker generates a list of patients overdue for retinal screening and invites them to attend on a particular day).