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The Staying Strong pilot project explored how telehealth can support ageing Aboriginal and Torres Strait Islander people with chronic health conditions. The project involved 136 participants across regional New South Wales and Queensland, including Armidale, Coffs Harbour, Goodna and Toowoomba. It trialled two telehealth models: in-home monitoring and hub-based monitoring through local partnerships.
The project responded to the difficulty many older Aboriginal and Torres Strait Islander people face in accessing health services in rural and regional areas. These barriers included remoteness, transport challenges and historic distrust of mainstream services. Participants also had high levels of complex illness. The project evaluation highlighted that 90 per cent were living with five or more chronic conditions, while 30 per cent had been admitted to hospital at least once in the last twelve months.
The approach combined telehealth monitoring of vital health signs with support from a registered nurse (RN), individual monitoring plans, triaging software and follow-up. Monitoring plans were developed by a participant’s usual general practitioner or a telehealth registered nurse, based on the individual health needs of the individual. Readings were transmitted to a central database. Telehealth registered nurses would follow up remotely if results were outside of an agreed range.
For those without broadband access at home, or who were unable to use the equipment independently, local telehealth hubs were established through partnerships with Aboriginal Community Health Centres. The telehealth hubs provided a private space for monitoring while offering nurse support during readings, plus an introduction to the technology through group-based support. The project also included intergenerational activities using broadband technology to support social connectedness and wellbeing.
Implementation was informed by consultation with key stakeholders, including Aboriginal representatives, through yarning and individual conversations. Registered nurses were employed at each project site and clinical governance was provided by integratedliving’s Care Services Team. While a project team with Aboriginal engagement capability supported delivery. One-to-one training was provided by a RN, helping participants to learn how to use the telehealth equipment in their own homes. The independent evaluation examined participant demographics, attitudes to technology, wellbeing, enablers, barriers and service outcomes.
Service use was supported by nurse follow-up and active general practitioner involvement. Evaluation findings reported that participants felt safer and more secure because someone was monitoring their results and would act on them when needed. It also found that most participants were able to use the equipment independently after two weeks of support. Follow-up survey results showed the technology was seen as clear, understandable, easy to learn and use.
The project also identified barriers to participation. These included family and kinship responsibilities, sorry business, visual impairment, cognitive impairment including dementia and mental health challenges. The report noted these factors could affect continuity of telehealth use. In some cases, participants needed support from a carer or more flexible arrangements in using the technology.
This case study shows that telehealth depends on more than equipment. It requires registered nurses with telehealth capability, clear clinical governance and practical supports for participants. Delivery models also need to respond to different levels of access, confidence and need. The report suggests that strong relationships between participants, registered nurses, general practitioners, and Aboriginal organisations were central to trust, uptake and continuity of the model’s success.
For providers and service leaders, this highlights the value of flexible participation options, local partnership-based delivery and ongoing support that helps people use the technology with confidence. The report also found that the remote monitoring model was estimated at 40 per cent less of the cost of face-to-face service delivery. It supported earlier intervention, more timely referrals and improved access to services.
This evidence-based example has been adapted from the original Staying Strong Pilot Project report to fit ARIIA’s case study format. For full detail and context, refer to the original report in the link provided.