• To identify the activities and outcomes of the nurse-led chronic kidney disease (CKD) management program.    
  • To determine the degree to which the program improved patient care including slowing progression of CKD to end stage kidney disease (ESKD) and the requirement for dialysis.

Aboriginal Australians experience a disproportionate burden of chronic diseases such as diabetes, heart disease and hypertension and are more likely to develop CKD and progress to the requirement for dialysis. In the Northern Territory the rates of progression to end stage kidney disease amongst Aboriginals Australians are between four and ten times that of non-Aboriginal Australians and in some regions this is as high as 30 times.

The need for earlier identification and evidence-based CKD management is now increasingly recognised as necessary to address the growing economic and public health burden. 

The Danila Dilba Health Service (DDHS) Kidney Health program was originally established under an Australian Government, time limited funded project for the care coordination of CKD in the NT. The program was subsequently absorbed into the Indigenous Chronic Disease Care Coordination and Supplementary Services program, providing ongoing funding and sustainability.

Implications for policy and practice: 

DDHS hopes this evaluation will help identify the impact the model has had on patient outcomes, in particular increased and earlier identification of people at risk of CKD and improved management of their condition, slowing the rate of progression to end stage and the requirement for dialysis.

Patient interviews will provide a greater understanding of the elements that make the program acceptable to patients and family and improve patient engagement with health services.

The evaluation will provide a basis for DDHS to improve the program and improve client outcomes in the future. 

Our research has found:

DDHS delivers an effective kidney health program through an expert team approach. The specialist nurse-led program provides DDHS with the capacity to increase screening and monitoring of people under their care and the expert team increases the organisation’s competence to recognise and effectively manage CKD and associated comorbidities. The program provides care and support throughout the patient journey including for those who choose no dialysis and palliation.

Chief investigator:
Project team:
Contact information:
Project dates:

October 2014 - March 2016.


  • Danila Dilba Health Service