The CONTINUUM project: Coordination of Long-Term Rehabilitation for Indigenous Patients to Improve Quality of Life and Outcomes

Participants in the intervention group will receive Navigator support for 12 months. A Navigator is someone from the health service, who can help support your rehabilitation journey by attending therapy appointments with you, helping with any questions that you have and going through your health care information with you, such as your medication plan. Patient Navigators are a relatively new and promising role to help patients with chronic diseases and long-term conditions navigate the complexities of the health care system. A non-clinical patient navigator provides practical, cultural, and emotional support to individuals throughout their rehabilitation journey, helping them overcome system barriers, coordinate services, and stay engaged in their care. By acting as a consistent point of connection between the patient, their family, and the wider care team, the navigator ensures that the rehabilitation pathway feels more accessible, supported, and tailored to the person’s needs. Aboriginal and Torres Strait Islander patients with chronic disease who are inpatients at the Royal Adelaide Hospital in South Australia will be invited to take part in the study. Eligible participants will be randomised in a 1:1 ratio to receive a 12-month program of Navigator support (intervention) or usual care (control group). Participants assigned to the intervention group will receive additional ongoing support in the form of coordinated care for their rehabilitation throughout the 12-month post-discharge period. Throughout the year, everyone will receive usual care and treatment appropriate to their chronic condition. Usual pathways of care for each individual, including multi-disciplinary rehabilitation program content, is guided by the associated clinical care Standards and Guidelines for each chronic condition in the areas of cardiac, stroke, Type 2 Diabetes-related foot complications and Type 2 Diabetes-related renal complications. All care required, whether physical, social or emotional is to be determined and discussed between the participant and their treating general practitioner, rehabilitation care providers and/or treating physician/s. Navigators will support participants to implement their individual rehabilitation plans, through care coordination including education; engagement with health care system navigation; promote patient understanding of their rehabilitation plan and work with participants and care providers to improve access and address barriers affecting access or adherence. Participants in the Navigator support (intervention) group will receive additional support and care coordination of their personalised rehabilitation program over and above the usual pathways of care. Participants in the Intervention group will be supported by rehabilitation care Navigators to assist implementation of their individual rehabilitation care plan, with additional ad-hoc support as required throughout the 12 month intervention period and reviews to occur as follows: first consultation prior to discharge from hospital, with the second consultation occurring within the first month post-discharge, then consultations at 3 months, 6 months and 12 months. Participants in the intervention group will have study visits and complete questionnaires at baseline (in-hospital), at 2 weeks, 3 months, 6 months and 12 months. Participant visits will be conducted face-to-face, online or by phone as needed. Navigator activity logs will be utilised to measure occasions and mode of service provided by the Navigator. All participants will receive updates through a regular newsletter. Optional activities in the project include participation in focus groups and/or interviews during the study and/or after participation in the study.