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Integrated chronic disease management
Page contents: Overview | Guiding principles | Initiatives | Building capacity for ICDM | Supporting peer self help | Resources | Further information
Overview
Integrated Chronic Disease Management can be defined as the provision of person centred care in which health services work with each other and the client to ensure coordination, consistency and continuity of care over time and through the different stages of their condition. Features of this care include:
- planned and proactive care intended to keep people as well as possible
- coordinated care using team based approaches
- evidence based care
- support for self management
- regular review and follow up.
All community health services (CHSs) provide care to people with chronic disease and are involved in the work of integrated chronic disease management. This includes improving the services they provide, and improving the coordination of care. Service improvements are underpinned by the Improving Chronic Care (Wagner) Model.
The following guidelines provide direction for this work and are targeted to all community health services and primary care partnerships (PCPs).
Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services October 2008 (606kb, pdf)
CHSs commonly also deliver Home and Community Care (HACC) services and are involved in the implementation of Active Service Models (ASM). There are many similarities in the policy, service delivery and implementation approaches of the two initiatives (ICDM and ASM). This means there are opportunities for the initiatives to build on and strengthen each other. The following paper has been developed to articulate these synergies and support organisations to coordinate the service improvements of the two initiatives.
Resource for providers of HACC and Primary Health Service (99kb, pdf)
Guiding principles
The guiding vision for ICDM is the delivery of a responsive, person-centred, effective system of care that aims to improve health outcomes and the quality of life for people with chronic disease. Specifically it aims to:
- Slow the rate of disease progression while maximising health and wellbeing
- Improve access to quality integrated multidisciplinary care
- Facilitate client and carer empowerment through self-management programs and approaches
- Actively engage GPs as part of a multidisciplinary coordinated approach, including the development of written care plans
- Reduce inappropriate demands on the acute health care system.
Guiding principles that underpin ICDM work include:
- Providing person-centred care, including support for carers and/or families of people with chronic disease
- Recognising that consumers are active partners in the management of their chronic disease
- Increasing choice and control
- Providing the right care in the right place at the right time
- Proactively promoting health
- Building a whole of service system response.
Initiatives
The State government has provided funding to some local government areas (LGAs) in order to build the capacity of the sector to:
- drive service improvements
- provide more services to people with chronic disease.
Funding initiatives include the Early Intervention in Chronic Disease (EIiCD) initiative, currently funded into 36 of 79 LGAs across the state; and the Diabetes Self Management (DSM) initiative funded into 25 rural LGAs across the state. EIiCD provides additional services to people diagnosed with chronic disease. DSM provides services to people living in rural areas diagnosed with type 2 diabetes.
Building capacity for ICDM
The department is supporting CHSs statewide to engage in ICDM work through a range of strategies. These include:
- Workforce capacity building activities - focused on change management, leadership, care planning and multidisciplinary practice
- Chronic disease incentive and innovation projects
- Resources – predominantly developed through the Industry Advisor project that ran between 2008 and June 2010.
- Forums – ICDM forums have been provided over the past 3 years and will continue during 2011
- ICDM clearing house – a mechanism for the sector to share practice wisdom and helpful resources and tools.
Supporting peer self help
The Health Self-Help Funding Program provides non-recurrent grants to health self-help groups across the State that are not eligible for other government grants. The primary objective of the program is to provide financial support to self-help groups. Self help groups provide peer support for people living with a chronic health condition or mental illness.
Resources
ICDM case studies, fact sheets and monitoring resources.
Presentations from ICDM forums.
Further information
Contact information for further queries.
