Beyond the Clinic Collaboration in Coen

In the remote Cape York community of Coen, aged care staff drive around community every morning, picking up people from their homes to come and have breakfast at the St John Community Care Centre .

In late 2016, Centre Coordinator Koi Njoroge (right), an Enrolled Nurse, noticed something was wrong with some of her breakfast regulars.  The women, who suffered from diabetes, were tired, weak and displaying symptoms of out-of-control blood sugar.

Koi decided to check the blood sugar of one of the women. It was 19.8 - 10 to 15 points above normal.

Koi asked the woman if she had insulin and was assured she did. She visited the woman’s home and found six boxes of insulin in the fridge, some of it expired. It was clear that while the woman did have insulin she wasn’t using it.

Something needed to be done.

Koi asked the woman’s family if they were comfortable with her helping her take her medication. They were, so Koi invited the woman to come to her office each morning to get her blood sugar tested and take her insulin.

Koi asked the woman’s family if they were comfortable with her supervising the woman to monitor her sugar levels and take her medication daily at the HACC.

The family were happy with this arrangement, so Koi invited the woman to come to her office each morning, next to breakfast room at the HACC, to check her blood sugar and give herself insulin.

The woman agreed and word got around. The CheckUP - funded Diabetes Nurse Educator Maureen Toner who works for Apunipima Cape York Health Council, heard about this from the CheckUP - funded Dietitian – Stephanie De Zilva - who also worked for Apunipima Cape York Health Council.

Both visited Coen monthly to offer services from the Primary Health Care Centre (QH).

Stephanie visited the St John Community Care centre each time she visited Coen and invited Maureen to come along to meet staff and clients at the Centre on an occasion when their visit coincided.

Maureen recognised a couple of other women at the breakfast table as diabetes clients requiring insulin, and having poor diabetes control.  

Koi and her staff agreed to assist these women also by supervising their monitoring and insulin administration daily at the Centre as they attended daily for breakfast.

They and their families consented to this arrangement

Maureen assisted Koi to make sure best practice health and safety guidelines were in place and that Koi had access to the supplies and support that she needed to support these three women.

‘Sometimes it’s impossible for people in these remote Indigenous communities to manage insulin at home,’ Maureen explained.

‘Supported care such as that offered in this situation can be a very effective model of care and has resulted in much improved diabetes control for these ladies, which we know equates to improved health outcomes.’

‘I had been trying to help support these ladies for quite a few years to self-manage their diabetes care at home with family support, but had not achieved the outcomes that have resulted from this model of supported care offered by the staff at the Coen Centre’ said Maureen

The CheckUP- funded doctor – who also worked for Apunipima – and visited Coen Primary Health Care Centre fortnightly, started visiting monthly to check up on the health of these women and others at the Centre.

Koi has also seen a dramatic change in the health of the three clients.

‘The turnaround has been nothing short of incredible’ said Koi. The patients are rapt, they are feeling better. They just needed a place to go and a bit of support.’