Table 1 Standardised and Contextualised elements of the intervention

Family-centred case management by IHW

· Qualifications of HW (min Certificate IV in Aboriginal and Torres Strait Islander Primary Health Care)

· use local PHC information systems

· Caseload 1.0 FTE:15-30 clients

· use local referral pathways

· IHW supernumerary to primary health care team

· use local care planning templates

· Training & orientation program (72 hrs face-to-face): Competency-based training in primary, secondary and tertiary health promotion interventions and clinical management of diabetes and COPD, CKD (Stages 1-3), hypertension and CHD

· use local education resources

· Supervisors attend orientation workshop

· Level and nature of contact with clients is at IHW’s discretion: ie they determine the appropriate language, resources, frequency and setting for care and education (home visits etc) according to client needs

· 6-monthly training (one week)

· Chronic Disease Guidelines (2010) as clinical governance protocol

· COPD screening with Piko 6 spirometer

System Support

· Trial manager

· Weekly support uses reflective practice technique, responding to the needs and context of each HW

· 2 FTE ICST for 6 HWs

· Problem solving for local context, eg working with local team to establish/facilitate care plan process, sorting contract issues etc

· Weekly report and plan

· Weekly meeting (phone or video)

· Remote clinical supervision of caseload

· Monthly IHW meeting by videoconference