Sustainability & Transferability of an effective community based management system for diabetes in remote indigenous com

该项目旨在改善昆士兰西北部偏远社区土著成年人的心血管疾病二级预防系统，并最终改善这一高危群体的患者预后。干预措施针对卫生系统的三个领域：社区和客户群体、临床服务和卫生管理系统。干预的重点是提高土著卫生工作者管理社区CHD召回和提醒系统的能力，并辅之以适当的培训和系统改革。该项目将与客户和社区团体密切联系，旨在提高客户有效自我管理心血管疾病的能力。这项研究将在两年多的时间里在3个地点和2个对照社区评估这种复杂干预的有效性

This project aims to improve systems for secondary prevention of CVD among Indigenous adults in remote communities in NW Queensland and ultimately to improve patient outcomes in this high risk group. The intervention is aimed at the three domains of health systems: the community and client group, clinical services and health management systems. The intervention is centred around increasing the capacity of Indigenous health Workers (IHW's) to manage recall and reminder systems for CHD in communities, supported by appropriate training and systems changes. The project will liaise closely with the client and community groups and aim to improve capacity for effective self-management of cardiovascular disease among clients. The study will evaluate the effectiveness of this complex intervention in 3 sites over two years, with 2 control communities