The congestive heart failure syndrome has increased to epidemic proportions and is cause for significant morbidity and mortality. Indigenous patients suffer a greater prevalence with greater severity. Upon diagnosis patients require regular follow-up with medical and allied health services. Patients are prescribed life saving, disease modifying and symptom relieving therapies. This can be an overwhelming experience for patients. To compound this, remoteness, differentials in conventional health care and services pose special problems for Indigenous clients in accessing care. Additional barriers of language, culture, socio-economic disadvantage, negative attitudes towards establishment, social stereotyping, stigma and discrimination act as barriers to improved care. Recent focus supported by clinical evidence support the role of chronic disease self-management programs. A patient focused, problem identification, goal setting and psychosocial modification based program should in principal highlight these issues and help tailor a patient focused comprehensive care plan to complement guideline based care. At present there are no Indigenous focused chronic disease self-management programs. There is a need for research on ways to provide chronic disease management to this group. We therefore designed a study to assess a model of patient focussed comprehensive care for Indigenous Australians with heart failure.

AUSI-CDS is a prospective, cohort, observational study to evaluate the efficacy of the standard “Flinders Program of Chronic Condition Management” for Indigenous patients with chronic heart failure. Eligible patients will be Indigenous, suffering from chronic heart failure, in the Northern Territory. The primary end-point is the satisfaction score based on the PACIC. The study will recruit 20 patients and is expected to last 12 months.

The rationale and design of the AUSI-CDS using the Flinders Model is described.