How coordinated care is helping Christine thrive
When Christine, a 70-year-old Aboriginal woman, was first referred to Sonder’s Closing the Gap – Integrated Team Care (CTG ITC) team, she was experiencing one of the most stressful periods of her life. Living with diabetes and a chronic foot ulcer, she had recently been told that without improvement in her wound healing, she could be at risk of losing her foot.
Christine lives with her daughter and receives support through a Home Care Package. However, the package didn’t cover the daily transport she needed to the Royal Adelaide Hospital for six weeks of hyperbaric treatment – a critical part of her wound healing process. After hearing about Sonder’s CTG ITC program through both her care provider and the Women’s Elders Group, she reached out for additional support.
Seeing the bigger picture
What began as a simple request for transport quickly became a more holistic effort to address of Christine’s health needs. During her initial CTG ITC assessment, Care Coordinator Carmen and Outreach Worker April took the time to understand Christine’s broader health picture.
They knew that better management of her blood glucose levels was essential for wound healing, but also understood that daily finger pricks were painful for Christine and led to inconsistent readings.
Carmen recalls, “When we first met Christine, she was highly motivated to avoid a foot amputation and was willing to do almost anything to support her wound heal.”
To help address this barrier, the team recommended a trial of a Continuous Glucose Monitoring (CGM) sensor – a small device that automatically tracks glucose levels, and provides reliable data to guide mediation adjustments. This information would support both Christine’s GP and Sonder’s Diabetes Educator, Rema.
Multi-disciplinary support in action
Once Christine agreed to the CGM trial, her care team worked seamlessly to put the plan in place. Sonder Dietitian Ceceilia joined the care team, collaborating with Rema to develop a nutrition plan that supported her treatment goals while respecting her lifestyle and preferences.
At the same time, Sonder’s Care Coordination team organised daily transport to and from the Royal Adelaide Hospital for her upcoming hyperbaric treatment.
Reflecting on Christine’s experience, Carmen shared, “Christine told us she felt really well supported by CTG. The taxis we arranged for her meant attendance at her hyperbaric treatment was stress-free.”
The road to recovery
In the weeks leading up to the hyperbaric treatment, Christine began noticing positive changes she never thought possible – all sparked by using the sensor. Her blood glucose levels stabilised, and her wound began to show significant improvement as a result. With less stress and more control over her health, Christine felt increasingly hopeful about her future.
Her GP and Podiatrist also reported major improvements. Her dressings now needed to be changed only twice a week, and her podiatry appointments reduced to once every three weeks. This meant fewer nursing visits, which freed up additional funds in her Home Care Package to support other aspects of her wellbeing and independence.
“Since I started using the sensor, my foot has really improved,” Christine said. “I’d had that ulcer for so long that I didn’t think it would ever get better. Now I feel so much more hopeful, and I don’t worry nearly as much about losing my foot. The Sonder team has been wonderful, and I’m just so grateful to have had this help.”
Christine’s hyperbaric treatment is now well underway, and combined with improved glucose management, her care team is optimistic that her wound could heal completely.
Looking back on Christine’s progress, Carmen said, “Christine is no longer at high risk of amputation as her foot wound is now healing well. It’s been incredibly rewarding to see her progress and to watch her regain confidence as her health improves.”
With stable blood glucose levels, clear signs of recovery, fewer appointments, and renewed confidence in her health, Christine is looking ahead to a future where she can focus on the things that matter most.
About the Closing the Gap – Integrated Team Care program
Sonder’s Closing the Gap – Integrated Team Care (CTG ITC) program offers free, culturally appropriate support for Aboriginal and/or Torres Strait Islander people living with chronic health conditions such as:
- Kidney disease.
- Heart disease.
- Lung disease.
The program brings together a team of Care Coordinators, Outreach Workers, and Aboriginal Health Project Officers who:
- Help clients understand their condition and build self-management skills.
- Support access to doctors, specialists, and allied health services.
- Provide transport assistance and encouragement to attend appointments.
- Connect clients with ongoing community supports to improve overall wellbeing.
Sonder’s CTG ITC program is available for people living in metropolitan Adelaide, Gawler-Barossa, Yorke Peninsula & Mid-North South Australia.
To get started, make an appointment with your regular GP or Aboriginal Health Worker. Ask them to complete an Aboriginal Health Check and/or a GP Management Plan and make a referral to Sonder.
If you do not have a regular GP, contact us at (08) 8209 0700 or email info@sonder.net.au and we’ll help you to access the service.
This service is supported by funding from Adelaide PHN and Country SA PHN through the Australian Government’s Primary Health Network Program.