Culture at the centre of community based aged care in a remote Australian Indigenous setting : a case study of the development of Yuendumu Old People ’ s Programme

Introduction: Yuendumu is a Warlpiri Aboriginal community 300 km north west of Alice Springs in Central Australia. Since emerging from the welfare period in the early 1970s, a range of services have evolved with the aim of developing a comprehensive community based aged care service. In 2000 Mampu Maninja-kurlangu Jarlu Patu-ku Aboriginal Corporation (Yuendumu Old Peoples Programme; YOPP) commenced operation to manage the developing services. This case study aims to describe, from the analytic standpoint of community control and cultural comfort, the main features of the ‘Family Model of Care’, which underpins the operations of the service and YOPP management processes. Methods: Data were mostly generated from participant observation by the authors in the development and management of YOPP between 1993 and 2009. A literature review of Indigenous history and public health in Central Australia was also undertaken, which was supplemented by a review of Programme documentation, including evaluations, needs assessments and annual reports. Results: The design and operations of YOPP are embodied in a documented ‘Family Model of Care’ which provides important lessons for the provision of aged care in a cross-cultural context. According to the concepts ‘community control’ and ‘cultural comfort’ outlined in this article, mainstream services can function in a complementary and supportive manner with professional


Introduction:
Yuendumu is a Warlpiri Aboriginal community 300 km north west of Alice Springs in Central Australia.Since emerging from the welfare period in the early 1970s, a range of services have evolved with the aim of developing a comprehensive community based aged care service.In 2000 Mampu Maninja-kurlangu Jarlu Patu-ku Aboriginal Corporation (Yuendumu Old Peoples Programme; YOPP) commenced operation to manage the developing services.This case study aims to describe, from the analytic standpoint of community control and cultural comfort, the main features of the 'Family Model of Care', which underpins the operations of the service and YOPP management processes.Methods: Data were mostly generated from participant observation by the authors in the development and management of YOPP between 1993 and 2009.A literature review of Indigenous history and public health in Central Australia was also undertaken, which was supplemented by a review of Programme documentation, including evaluations, needs assessments and annual reports.

Results:
The design and operations of YOPP are embodied in a documented 'Family Model of Care' which provides important lessons for the provision of aged care in a cross-cultural context.According to the concepts 'community control' and 'cultural comfort' outlined in this article, mainstream services can function in a complementary and supportive manner with professional

Background to Yuendumu and the Old People's Programme
Yuendumu, the largest Aboriginal community in Central Australia, has a fluctuating population of approximately 1100 Warlpiri people, and is situated 300 km north-west of Alice Springs on the edge of the Tanami Desert (Fig1).The people (who refer to themselves as Yapa) speak predominately Warlpiri with English as a second or third language.
Yuendumu was established as a ration depot and mission in 1946 with a then estimated population of 350 1 .Much of the work of old people in their youth was for government rations not wages 2 .As part of this 'welfare time', government rations were distributed at Yuendumu from the 1940s until 1970s.A community kitchen and dining room was also in operation from the early 1960s.After communal food provision ended, there were community reports of undernutrition in young children and the elderly.After the end of the 'welfare time', local women started providing meals to old people from a base at the local health clinic.Later, a community based Meals on Wheels service commenced and in 1988 the Yuendumu Women's Centre was established to support this service with funds from the Home and Community Care (HACC) program of the national government (Commonwealth Government).In 1993, the Women's Centre employed a Project Officer for a training and development project (the present lead author).At this time, a large number of old people from Yuendumu were living permanently in nursing homes 300 km away in the town of Alice Springs.Territory Health Services (managed by the Northern Territory Government), for the first time in Central Australia, seconded two Aboriginal health workers to provide personal care services at the outset of service development.
As is common in remote Aboriginal communities, the economic context of Yuendumu is characterized by high unemployment rates, low household incomes and poor standards of housing.There is a range of service providers in Yuendumu, including the Women's Centre, Health Clinic, Warlukurlangu Arts Centre, Youth Services, Warlpiri Media Association, police, two locally owned shops, education services and the Community Council.All these services impact directly or indirectly on the quality of life of old people.Non-Aboriginal professionals administer most of these services.
Included in this range of service providers is an aged care service known as Yuendumu Old Peoples Programme (YOPP).This case study aims to describe, from the analytic standpoint of community control and cultural comfort, the main features of the 'Family Model of Care', which underpins the operations of the service and the YOPP management processes.

Sources of information
This case study was undertaken based on 16 years of participant observation in the development, implementation and management of YOPP.In developing this case study, the authors reflect on the experience and discuss issues with reference to relevant international, national and Programme literature and documentation between 1993 and 2009.
The first author was the YOPP facilitator for 11 years between 1993 and 2004.This participation has provided a rich source of information in terms of historical record, and the continuous engagement in management and delivery of services has enabled participant insight into the evolution of YOPP.While working in YOPP the first author kept a daily journal.From this journal, monthly and six-monthly reports and annual reports were written for the funding body and Steering and Management Committees.Additional historical material was recorded in two video documentaries produced in 1995 and 2004 3,4 .The third author is the senior Warlpiri community member overseeing the local Management Committee.It is the cultural perspective of the third author and his community members that has provided the main cultural frame for the shaping of YOPP that is documented in this article.

Limitations and scope of the case study
In conducting the literature review, very little published material was found about aged care in remote Aboriginal communities, and no material described an Aboriginal cultural framework for developing or delivering aged care services.Additionally, at the outset of this project there was an absence of accurate baseline data regarding the community of origin of Aboriginal people permanently residing in Alice Springs nursing homes, which is a limiting factor in describing Programme impact.However, the emphasis in this article is on quality of care, with the description of cultural processes being central to the definition of quality and the model of service delivery.In addition, while a comprehensive account of the development and operations of YOPP cannot be provided, the most significant features believed to be of benefit to other aged care programs in Indigenous communities have been highlighted.Finally the authors acknowledge that neither testing aged care clinical standards nor formal evaluation of community perceptions of quality of care were objectives of this article.Rather, the primary aim was to describe the development of a Family Model of Care and articulate the role of cultural and community factors in shaping the aged care program.

Approach
The development of YOPP was based on action research principles and problem solving strategies.Essentially this means that the workers negotiate current priorities to address using the Action Research Cycle of: identify and plan -actobserve -reflect/evaluate.This process allows existing services to be consolidated and improved while identifying and trialling ways to meet new issues as they arise 5 .In an unpredictable environment with constant community disruption, this method of continuous consolidation and review assists to keep planning informed by the immediate needs of the client group and enables response to unforeseen circumstances.It also enables the development process to accommodate the core Warlpiri values of immediacy, mobility and intimacy that influence the priorities of everyday life in the community 6 .These values are shaped by notions of time and space, kinship and country.High value is placed on orientation to the present, meeting needs as they arise, being in the close company of family members, ongoing negotiation of social relationships and responsibilities, and, continual movement within and among camps and other Warlpiri communities (Figs3,4) 1,6 .

Frameworks for development and analysisconcepts of cultural comfort and community control
The concepts of 'cultural comfort' and community control are fundamental to understanding the rationale for the design and mode of management and operations of YOPP.
From the outset of the development process the aim has been to minimize the number of old people in the community being permanently admitted to Alice Springs' nursing homes by providing support and respite services to enable them to live in their family groups and 'finish up' (pass away) in their own country.To achieve this, services need to be provided to ensure cultural comfort.
The concept of cultural comfort means that service provision is informed by, and provided from within, Warlpiri cultural practices rather than Warlpiri needs being accommodated within another cultural construct.This approach is similar to the notion of cultural safety 7,8 , which directly links service actions with protocols and procedures according to local practices 9 .Furthermore, cultural safety involves a critical examination of the power imbalances in healthcare encounters between Indigenous clients and non-Indigenous healthcare providers 10 .Cultural comfort is an expansion of this concept of cultural safety, in that it recognizes local culture as being the starting point for the design of service provision, rather than being a factor in design that needs to be accommodated to a mainstream culture.
The concept of 'community control' is also central to the design and operations of YOPP.Community control means that planning is undertaken at the community level according to the priorities set by community people and their perceptions of the timing and pace of development.It also involves the notion of building community capacity so that individuals and communities can better address and manage their own care needs 11 .This being the case, the community control approach is considered a central strategy to addressing the social determinants of health through enhanced accessibility to healthcare services 12 .In practical terms, this means that management of the day-to-day activities of services should be in the hands of local people 12 .
A Programme Development Plan from 2000, which included an evaluation of the existing Programme, indicated that local cultural constructs such as the Family Model of Care, the kinship system and the local governance model were all attributed as being main factors in the very high acceptance of the service by community members 13 .
From the analytic standpoint of community control and cultural comfort, this case study aims to describe the main features of the 'Family Model of Care' that underpins the operations of YOPP.The article will also discuss the implications of this aged care delivery model as a strategy for community development and enhancement of quality of care.

The Health Needs of the Aged in Yuendumu
In 1993 there were many old people from remote Aboriginal communities in Central Australia residing permanently and reluctantly in nursing homes in Alice Springs 14 .In Yuendumu at this time there were no records of old people, either in nursing homes or in family camps, available in the community.Thereafter, Clinic records and the old Welfare family records book (locally known as the 'stud book'), were used to compile an annually updated YOPP register of all those over 50 years of age.In 2001, approximately 10% (110) of the population were identified as 'aged'.Most of these were widows living in single women's camps or with young family members.All, except the very frail and infirm, were involved in the cultural and ceremonial life in the community.
The healthcare needs of the old people are both chronic and acute.The Old People's Programme maintains a high proportion of 'high care' clients in the community.While it is possible to support people to 'age in place', medical interventions often result in referrals to higher levels of the healthcare system which results on occasions in old people not 'dying in place' 15 .For the first 5 years of YOPP's increased service provision and planned respite care, no one from the community was permanently placed in an Alice Springs nursing home.Since then, four to five individuals at any one time have lived permanently in a nursing home in Alice Springs 16 .
Client numbers remained fairly constant during the period of this case study with 25-35 clients (of which 15-17 would be considered 'high care' mostly being frail aged people, but also including those with conditions such as dementia, suffering from immobility and/or requiring continence management).The birth cohort of this initial client group preceded the settlement period and consequently lived nomadic, traditional life styles as children and young adults.
Recent years have seen the emergence of a younger client group with chronic health problems such as diabetes and renal failure related to the more sedentary life styles of the settlement period 16 .

The development of YOPP
In the early 1990s there were no precedents for aged care services beyond basic Home and Community Care services in remote Aboriginal communities.However, the Commonwealth Government was supportive of communities negotiating locally appropriate services.These were supported by the Aboriginal and Torres Strait Islander Aged Care Strategy 17 .After a period of Pilot Project funding (1997-2002) YOPP began to receive funding as a Flexible Aged Care Service in 2002, with the 'flexible service' design of a mix of residential and community based aged care services 18 .As a result of these developments, YOPP has been supportive of old people staying with their families in the community and to 'finish up' (pass away) in their country.A 1993 needs analysis 19 , minutes of YOPP Management Committee meetings 20 , and the Constitution of YOPP 21 record the concern of old people and others in the community regarding community members permanently resident in nursing homes in Alice Springs (and subsequently passing away outside traditional country), and the expressed and related need to develop community based quality agedcare services.Despite not being the largest Aboriginal community in the Northern Territory, Yuendumu has the highest number of high care old people in the community.The last decade has seen an average of only four elderly people (of an average population of 100 elderly) permanently residing in nursing homes in Alice Springs 22 .

The Service delivery model -'The Family Model of Care'
Principles of operation: The concepts of cultural comfort and community control are embedded in the model of Mainstream concepts of quality of care are acculturated within a Warlpiri worldview.The Warlpiri worldview incorporates people's local reality, their wishes and ways of thinking, priorities, needs and constraints.As part of this worldview, care is provided within the context of the obligations and responsibilities of the Warlpiri family and skin group system.This kinship system provides the main framework within which the Warlpiri make significant decisions, as well as defining the network of correlative roles and social behaviors 23 .
Traditionally it was 'kin' rather than 'the community' who cared for the aged and the weak.In Warlpiri culture, the old people are the 'keepers of culture'.This being so, the workers must have the right standing in the community and be trusted to look after old people who have contributed significantly to the ceremonial and social life of the community.It is recognised that the client group 'grew up' the young people and, in return, the young people are now required to help 24 .This model emphasises, reinforces and supports family care, as opposed to the more mainstream institutional human service model.It reflects the mission of YOPP to maintain old people in their families and in their country, even when they are very frail and have high care needs, and to help them to 'finish up' (pass away) in their community 25 .
YOPP aims to improve the quality of life and quality of death for old people and keep them living in their country with their families.We are moving away from institutional care back to the family model of care that once was so strong 15 .

Methods of operation:
This Family Model of Care emphasizes the relationship between culture, control and self-reliance, and connection with the wider community.
Cold weather is here and everyone has to help old people.It is too big a job for the Old People's Programme by itself 25 .
There are three ways for community members to initiate care and comment on or evaluate the appropriateness of the services.These are through the Management Committee, Senior Worker and/or Project Worker and the Aged Care Workers.Any member of the community can approach appropriate Management Committee members or workers with issues of concern without breaching cultural protocols.• Accommodating physical design and space of YOPP's building to cultural factors (eg.requiring separation of women's and men's space, and meeting requirements of avoidance relationships)

Figure 3: Subject areas of cultural protocols.
In the Warlpiri world everything belongs to one of eight relationship classifications that determine how to relate to the other classification groups.These groups are known as 'skin groups' and are referred to as a classificatory kinship system.All Yapa are born into this system and it is the basis of all interaction.Skin relationships determine responsibilities between individuals in relation to care, land, ceremony and spiritual matters.Interpersonal relationships are also determined by this system.In practical terms this means that everyone in the same classificatory group are siblings, individuals they may marry belong to a specific group, and, the roles, obligations and responsibilities each person performs are determined by the classification they occupy in relation to others in this system.
In terms of providing services, YOPP workers usually work in pairs that are compatible according to this system and are matched with clients in groups they have particular responsibilities for such as siblings, parents and grandparents.In moving about the community, there are some people who must not come into direct face to face contact with each other or have any direct contact.These include first cousins of the opposite gender and those who have conducted certain ceremonial duties for family members.Those who stand in these actual or classificatory relationships to one another must give each other 'room' to carry out activities.
Examples of the relationship between the kinship system and YOPP operations include the following: • waiting outside the shop until those to be avoided have left the area; • workers swapping mid-task, such as delivering meals, so no one risks coming into contact with someone they are required to avoid; • only certain groups may handle the personal effects of others so carrying out tasks such as laundry or personal care for individuals must be done by those who have the appropriate relationship to the client; • having two doors with glass panels into every room in the aged care facility used by both genders, so that people can view those they are required to avoid before entering the same room; • having separate male and female ablution areas, verandahs and entrance gates so people with avoidance relationships are able to receive services at the facility without compromising cultural constraints.

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General meetings held with a visual separation between men and women's seating areas so as to accommodate all visual avoidance.Members also speak 'to the meeting' rather than provide direct comments to individuals.If there is a complex situation, a meeting will be organised by YOPP with the family, workers and health clinic staff to determine a care plan for the old person.If the issue is more than a service provision matter it may need to be taken to the Management Committee.As an outcome of these discussions, referral is provided that enables the appropriate level of service to be delivered.In this way, service provision can respond to the cultural, family and physical needs of old people.Review and evaluation is on-going with all parties by the involvement of all 'skin groups' in the management and organisation of care.
The advantages of the Family Model of Care include the following: • reinforcement of Warlpiri social systems • skill building within family groups to care for old people • care planning and review that is responsive to the expressed needs of the old people and their families • continued access to care for old people even during 'sorry' (mourning ceremonies), because the carers are in the ceremonial group • employment for community members • enablement of community members to access support services without compromising cultural protocols.

The process of managing YOPP
The Old Peoples Programme's management is based on three approaches: (i) participation and input from clients: (ii) Aboriginal driven management structure and processes; and (iii) consensus decision-making.
Participation: There are a range of strategies for accommodating participation and input from clients.
Independent incorporation ensures, through a legal entity, that there is an organisation dedicated to old people in the community that is not subjected to the changing priorities of  The Management Committee is responsible for dealing with the direction of YOPP, planning, complaints, problem solving and ensuring the services are 'straight' (a colloquial term meaning honest and according to the rules).The Committee meets regularly with special meetings held as required, and annual general meetings are held with all members of the Corporation.Committee members are available to workers for advice, support and approvals.The Senior Worker is responsible for the day-to-day issues of service delivery, monitoring YOPP, supporting and training staff.She is available to review a situation, organise family meetings and ensure that the service is adaptable to the cultural activities of the community.

Consensus decision-making:
Workers make decisions through a consensus process, following discussion with the appropriate people/services.This is facilitated by management activities that include senior staff discussion, family meetings, Management Committee meetings, annual general meetings with clients and members, monthly meetings with Clinic staff and ongoing communication with family carers.
The Management Committee also makes decisions by consensus.Decisions are deferred if agreement cannot be reached.The men and women will sometimes hold different views of how best to address an issue.Each view point is heard during meetings but consideration and discussion of issues take place in family groups.Meetings are forums to examine information and reach agreement, rather than to debate issues and argue a particular stance.This can make decision-making a slow process but leads to well-considered decisions that maintain accord in the group.During the period of this case study many serious social and political matters, both from within the community and the outside world, were successfully resolved by the Management Committee 22 .

Sustaining Yuendumu Old People's Programme
The Old People's Programme is able to accommodate some of the community, social and cultural needs of the people.Staffing levels can be erratic when family and community life demand the attention of the workers.However, there is a large pool of casual workers to be drawn on.For example, on most occasions of service disruption due to other local matters, people who are able will come forward and work in YOPP.In this way family obligation or cultural commitment is usually met with minimal disruption to service delivery.In recent years there has also been some ceremonial adaptation to allow workers to maintain service provision during ceremonial periods.
The legacy of welfare dependence combined with social and political upheavals, high rates of trauma and death, the extreme physical environment and complex cultural issues all lead to difficult situations to negotiate and navigate, making it very difficult for short term outside or non-Yapa employees to work effectively with local people.
Consequently, the importance of long term personal relationships cannot be underestimated in sustaining the success of service provision in a cross cultural setting.These relationships are able to initiate and accommodate change over time, rather than implement new ideas quickly that cannot be sustained.

Community development context of aged care
Given the history of welfare dependency and the emphasis on cultural and family models of care, there is a strong Culture is, therefore, not seen as something at the margins of a service delivery framework.It is at the centre of development 29 .Culture operates through the way YOPP is managed by the skin-group based Management Committee.Culture operates in the service delivery system via kinship relations among workers, clients and 'country'.Culture is at the centre of the physical infrastructure of YOPP, which is designed to accommodate the traditional organisation of domestic camps, gender relationships to space, and avoidance relationships.Finally, culture is placed at the centre of personal care because the primary provision of care is by Warlpiri people for Warlpiri people.
It is important to understand that accommodating a Warlpiri worldview into the pattern of service delivery goes beyond a statement of recognition by mainstream services of culturally mediated alternative patterns of service delivery.Associated mainstream services must also adapt their service delivery pattern and management in order to accommodate this Warlpiri worldview.This is because working at the aged care cultural interface means change from both sides, not the least of which is a recognition of 'mutual paradigms of competence' between the two groups 30 .This involves a way to be found for both cultures to understand each other's values and priorities.In practical terms this requires agreed communication mechanisms for operations, which in the YOPP case includes the Management Committee, the Family Model of Care and national standards and guidelines for aged care practice.In particular, it is the centrality of culture to management and service provision that provides 'cultural comfort' and enables the provision of optimal quality aged care services in an Indigenous setting.
The challenge of having two cultural paradigms interacting in the health sector has also been observed in the legal sector.For example, strategies for Aboriginal dispute resolution are said to 'maximize and enhance the role of community elders and organizations and minimizes… the reliance on external agencies and inappropriate dispute resolution mechanisms' 31 .However, sole reliance on external agencies was said to have contributed significantly to 'the disempowerment of Aboriginal people in law and justice on these communities' 31 .In the same way, sole reliance on mainstream health and urban aged care services was viewed as contributing to the disempowerment of family and community based aged care in Yuendumu.This was therefore viewed as impacting negatively on quality of care by denial of family and old people's aspirations to live and die in traditional country.
This observation has been supported by a recent review on end of life care for Indigenous people in Australia, which established that a lack of Indigenous respite services in rural and remote areas was obstructing patients' wishes for their death to occur in the local community, and resulting in many patients dying in far away cities 32 .
The structure and function of YOPP is, therefore, consistent with the fundamental principles of community development, particularly in regard to the promotion of self-reliance, community ownership and careful management of outside external expertise 33 .

Ideas of quality of care in a cross cultural context
If judged according to the 'efficiency standards' of non-Aboriginal organizational culture, Warlpiri decision-making processes can be seen as slow.However, this process, which requires the provision of time to consider and discuss issues

Figure 1 :
Figure 1: Map of Australia locating the community of Yuendumu.
service delivery that came to be referred to as 'The Family Model of Care.' Yuendumu Old People's Programme is based in the traditional values, skills base and worldview of Yapa.'Hands on' services are delivered primarily by local people who speak Warlpiri and are known to the client group.They function within local cultural protocols (Fig3), and hence are uniquely positioned to understand and accommodate the day-to-day activities and concerns of the clients.That is, the 'commonsense' behaviors of Warlpiri society are applied to the service delivery model.

Figure 4
Figure4provides more explanation of the skin group system and its applicability to the aged-care context.

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Kinship obligations and relationships • Family and cultural obligations • Avoidance Relationships (ie.avoidance of community members that are within a specific kinship or ceremonial relationship) • Specificity of gender roles • Utilization of mechanisms of demand sharing and the exchange and circulation of material goods in relation to reciprocal relationships and behaviours • The practice of spiritual beliefs • The high value placed on mobility of clients and their families, • The significance of fire, • Preferred foods and cooking methods, • Sleeping arrangements,

Figure 4 :
Figure 4: The Kinship System in the context of aged care.
Strategies put in place by YOPP have also benefited the whole community.These include provision of washing machines throughout the community (resulting in greatly improved skin conditions and general hygiene), and an open approach to employment and training (enabling community members to develop care skills that improve family and community safety).Employment with YOPP has provided many women in the community with the opportunity to extend their knowledge of nutrition and cooking.
sponsor bodies.Membership of the organisation is open to people permanently living in Yuendumu over the age of 50 years, workers who have been employed for more than 12 months and anyone the Management Committee considers works for the benefit of old people.Kinship relationships and obligations are accommodated by YOPP by having a number of people who can be approached if someone has a problem or concern about the service.Workers are matched with clients to ensure cultural protocols are maintained.The workers also self-select their working partners according to these protocols.Aboriginal management structure: To ensure all family groups are represented in YOPP and to reflect the client gender ratio, the Management Committee consists of eight women (representing every skin group) and four men (representing every father/son group).

Figure 5 :
Figure 5: The Family Model of Care.
Continuity, stability and appropriate working relationships within YOPP have been further maintained and restored through the Management Committee's commitment to local control and the employment of local workers, in keeping with cultural considerations.The daughters, sons and grandchildren of the original local workers and committee members are the current workers in YOPP.Development of the services provided by YOPP has been progressed by the community development practices of support and skills development of local people by outside professionals who do not have a permanent presence in the community.A central sustainability strategy in the development of Aboriginal governance was therefore the '2 week in -2 week out' approach adopted by the non-YapaProject Worker.This approach to development partnerships (intermittent presence of specialists in the field) has been noted in other development contexts26,27 .The sustainability strategy works through the promotion of self-reliance among the local aged care workers and their managers, and ensures continuity of the non-Yapa Project Worker position by preventing 'burn out'.This reinforces local ownership, independence and provides space for culturally appropriate practices to be determined.Yapa workers are able to be 'bosses for themselves' while knowing that support will return.In this sense, the Project Worker acts as a 'change agent', 'mobiliser' or 'facilitator' and the Senior Yapa Workers and key Committee members are 'animators' of the development effort26  .The skills of the workers are developed by formal and informal training that utilises Aboriginal learning behaviours of modelling, observation and imitation, trial and error and real-life application28 .
emphasis in YOPP on self-reliance.In a community development context, this means building on the traditional precedent of caring for old people to develop capacity.In this way the local organization and local workers are enabled to work with families and to care for old people in a flexible and culturally appropriate way.It also means assisting families to maintain traditional ways of caring for older family members while providing new support services to complement and sustain traditional patterns of care.Working in a community development context involves matching workers' priorities and needs with those of the service.For this to occur, flexibility in relation to time management and changing personal and community priorities is required.Finding culturally sustainable ways of meeting the needs of the client group and of the local workers as individuals and culturally responsive members of Warlpiri society is required.A trial and error approach to service planning is needed to accommodate a Warlpiri way of delivering services.
Ideas of 'quality of care' are, therefore, not centered only on standards of medical competence.Culture is also at the centre of care, and so quality begins with issues of traditional law, country, and kinship.Mainstream services are accommodated within this quality concept by being accountable to a management system governed by the structures and functions of tradition.The local Management Committee, organized along kinship lines and operating according to the Family Model of Care, is the principal mechanism by which problems are solved, family issues are negotiated, and care is organized.The presence of the Project Worker at Committee meetings ensures there is always a pathway of communication between the service providers and community leaders.Honoring clients' right to decline services and advocating on their behalf to 'age and die in place' are important aspects of the organisation's cultural responsibilities.Rather than accepting the concept of a dominant mainstream culture, YOPP demonstrates that there are, in fact, two 'coherent and competent societies in relationship'30  .Local acceptance and the effectiveness of YOPP is dependent on recognition of a paradigm of mutual competence, and the development of practices by mainstream professional carers that are supportive of traditional systems of care based on traditional law, kinship and country as well as on standards of medical and aged care competence.In this sense, discussions of 'community control' and 'cultural comfort' are not merely 'holistic' concepts of Aboriginal health that can justify any answer to a policy question34 , but can also have practical applications in the everyday setting of community based aged care.ConclusionYuendumu Old People's Programme emerged from a long period of 'welfarism' to become a meals on wheels service and then, in 2009, a more comprehensive community controlled aged care service.The needs of the old people in Yuendumu are regarded as significant, based on the particular social and economic conditions of poverty and remoteness, and the desire of the old people to live and die in their traditional country.The key lesson of this case study is that it is feasible to promote high levels of cultural comfort and community control in an Indigenous aged care setting, and that these characteristics should be used to assess quality of care in such a context, along with the accommodation of medical and mainstream aged care standards.The Old People's Programme has demonstrated these characteristics in helping to meet the needs of the old people by placing culture at the centre of service provision, and devising management and operational principles and strategies that ensure that the old people have the best chance of 'ageing and dying in place', close to family and country.Health and Ageing, the Aged Care Workers of YOPP, the Management Committee of YOPP, many senior Yuendumu community members who have now passed on, and Flinders University (Centre for Remote Health).Special thanks are extended to Christine Lennard, Dr Melissa Lindeman and Lorraine Nungarrayi Granites for their assistance with the content, and to Flinders University for financial assistance through a bursary (PHCRED).