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

INTERVENTION: 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 associat CONDITION: Cardiovascular ‐ Coronary heart disease Chronic disease;Coronary Artery Disease;Heart Failure;Ischemic stroke;Intracerebral haemorrhage;Subarachnoid haemorrhage;Type 2 Diabetes‐related Foot complications;Type 2 Diabetes‐related Renal complications; ; Chronic disease ; Coronary Artery Disease ; Heart Failure ; Ischemic stroke ; Intracerebral haemorrhage ; Subarachnoid haemorrhage ; Type 2 Diabetes‐related Foot complications ; Type 2 Diabetes‐related Renal complications Metabolic and Endocrine ‐ Diabetes Physical Medicine / Rehabilitation ‐ Other physical medicine / rehabilitation Renal and Urogenital ‐ Kidney disease Stroke ‐ Haemorrhagic Stroke ‐ Ischaemic PRIMARY OUTCOME: Quality of Life[SF‐36 Questionnaire baseline, 3 months, 6 months and 12 months post‐intervention commencement] SECONDARY OUTCOME: Navigator Activity[Composite of Number of Occasions of Service (OoS) and Mode of OoS provision (e.g. face‐to‐face, phone, telehealth) recorded via Navigator Session Log From baseline to 12 months post‐intervention commencement for each navigator contact] Number of days in hospital[Length of stay for hospitalisations 12 months post‐intervention commencement] Number of repeat hospitalisations[number of re‐hospitalisations from medical record review and/or participant report via study specific questionnaire 12 months post‐intervention commencement] Out of pocket healthcare expenses[Out of pocket healthcare expenditure patient reported measure (OOPHE PRM) survey 6 months and 12 months post‐intervention commencement] Survival status[Vital status/Date of death from medical record review and/or participant report 12 month end of study visit] Wellbeing[What Matters 2 Adults (WM2A) culturally grounded wellbeing measure ; Patient‐reported outcome (PRO) ; baseline, 3 months, 6 months and 12 months post‐intervention commencement] INCLUSION CRITERIA: 1. Self‐identify as Aboriginal and/or Torres Strait Islander 2. Age 18 years or over 3. Able to provide informed consent 4. Inpatient at the Royal Adelaide Hospital with one or more of the following chronic conditions: i) Coronary Artery Disease or Heart Failure ii) Stroke (ischemic stroke, intracerebral haemorrhage or subarachnoid haemorrhage) iii) Type 2 Diabetes‐related Foot complications: below, through or above knee amputation, midfoot (minor) amputation, toe(s) amputation for diabetes, toe (1‐5 toes) or ray amputation iv) Type 2 Diabetes‐related Renal complications: estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m^2 and not on renal replacement therapy 5. Individuals for whom their clinical team deem specialised rehabilitation to be most appropriate 6. Usual place of residence geographically located in one of the participating areas