Community-led virtual care shows promise for Indigenous chronic disease management

Anyone who works in health care in rural or remote Australia knows what the challenges look like. Behind every statistic is a person forced to travel hundreds of kilometers for care, a clinician stretched beyond capacity or a community left without the services it needs. These inequities are particularly stark for Aboriginal and Torres Strait Islander Peoples.

Aboriginal and Torres Strait Islander males born in 2020–2022 can expect to live 71.9 years, and females 75.6 years. Indigenous people experience disease burden at 2.3 times the rate of non-Indigenous Australians, and chronic conditions account for about 70% of the health gap.

These figures are more than statistics; they represent lives cut short, preventable suffering and a level of health inequity that should not exist in a country as advanced as Australia.

Behind these numbers is a clinical problem of continuity of care. Conditions such as diabetes, hypertension, cardiovascular and chronic respiratory disease are not managed in a single consultation but over years, in small increments.

Successful treatment depends on the patient coming back. But when the nearest clinic is an hour or more away, transport is unreliable and mainstream services are culturally unsafe, patients may not come back at all.

Digital health innovations—home-based devices, remotely reviewed health data and video consultations—are often presented as the solution, particularly where distance and workforce shortages make continuity of care difficult.

Yet experience elsewhere suggests new technologies can inadvertently benefit those who already have reliable access, connectivity and support. Before these approaches are scaled more broadly, we need a clearer understanding of who is using them and who is being left behind.

In rural southwest Queensland, Goondir Health Services, a community-controlled Aboriginal Health Service, is showing what virtual care can look like when built around Aboriginal and Torres Strait Islander clients, local relationships and continuity of care.

Goondir gives clients four home monitoring devices (blood pressure monitor, weight scale, blood glucose monitor and pulse oximeter), reviews their readings regularly through linked clinical dashboards and supports them with Aboriginal and Torres Strait Islander health coaches.

What the research found

In the first of two studies, researchers examined engagement among 74 adults with chronic conditions enrolled in the service. Almost two-thirds (64%) were active users, and most used all four devices regularly rather than selectively using one. The findings were published in BMJ Open.

Engagement was significantly higher among adults ages 18–65, those living with multiple chronic conditions and residents of medium rural towns than among those in more remote communities. Interestingly, patients with the most complex needs were the most engaged.

The second study, appearing in Quality of Life Research, measured health-related quality of life in the same cohort and projected the loss across their remaining lifetimes in quality-adjusted life years (QALY), with one QALY equivalent to a year lived in full health.

Adults ages 55–64 faced the heaviest losses, with a projected shortfall of 4.4 QALYs across their remaining lifetimes (equivalent to about four and a half years of full health lost to chronic diseases).

Patients 75 and over reported quality of life above general population norms, likely reflecting a survivor effect.

The results show the burden of ill health falls in prime working years rather than in old age.

What follows next

The evidence suggests community control is not simply a supporting feature of the technology—it is the active ingredient that makes it work.

When care is designed, governed and delivered by an Aboriginal and Community Controlled Health Organization, and when a trusted local health coach bridges the gap between the patient and the technology, people engage.

This research also shows where investment is needed.

Engagement tapered off among older patients and in the most remote communities, precisely where connectivity is poorest and the Aboriginal and Torres Strait Islander health workforce is most constrained.

Three priorities stand out.

First, funding for community-controlled digital health must run long enough for these models to become embedded and trusted.

Second, investment is needed in the Aboriginal and Torres Strait Islander health workforce, particularly health coaches and Aboriginal Health Workers in remote communities. A device can collect data, but it cannot build trust or understand family circumstances like a health coach who knows the person, the family and the community.

Third, it is vital to recognize digital connectivity in rural and remote Australia as essential health infrastructure, not a telecommunications afterthought.

These findings suggest that Aboriginal and Torres Strait Islander patients in their fifties, often balancing work, family responsibilities and multiple chronic conditions, face some of the greatest projected losses of healthy life.

Encouragingly, they also appear among the most willing to engage with virtual care.

The evidence points toward a model reaching those who need it most. The task now is to strengthen and expand it so no community is left behind.

Who’s behind this story?

Sadie Harley

BSc Life Sciences & Ecology. Microbiology lab background with pharmaceutical news experience in oil, gas, and renewable industries.

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Andrew Zinin

Master’s in physics with research experience. Long-time science news enthusiast. Plays key role in Science X’s editorial success.

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