Integrated Chronic Disease Management

Overview

Integrated Chronic Disease Management (ICDM) includes the following:

• planned and proactive care intended on keeping people as well as possible rather than responding to an illness
• empowering, systematic and coordinated care that includes regular screening, support for self management, assistance to make lifestyle and behaviour changes
• care that is provided by a range of health services and practitioners (eg. GPs, podiatrist, physiotherapist, counsellor, dietitian, nurse, specialist, dentist)
• care that is provided over time through the stages of disease progression

The Wagner Chronic Care Model, with its six interdependent elements, provides the framework for Primary Care Partnerships to develop a service system for improving the care of clients with chronic and complex care needs.

An online Wagner Chronic Care toolkit provides step-by-step descriptions of the specific changes involved in Chronic Care Model implementation, including more than tools, strategies to address financial and operational barriers to quality improvement and case studies of successful quality improvements and service system developments to improve chronic care.

Planning, implementation and program guidelines have been developed to support PCPs and their member agencies, including primary health care services in the development of ICDM across the service system. In particular, these guidelines support the planning and implementation for the Early Intervention in Chronic Disease (EIiCD) initiative, a key component in the broader work being undertaken in health service system reform.

A number of case studies outlining examples of good practice in ICDM, and fact sheets providing specific information and guidance related to particular ICDM topics have been developed. They have been designed to respond to common issues encountered by PCPs and agencies in planning and implementing ICDM initiatives.

Integrated Chronic Disease Management Clearinghouse

The Integrated Chronic Disease Management Clearinghouse, hosted by the Australian Disease Management Association (ADMA) has been established to support the work of all Victorian clinicians and services engaged in chronic disease management. The purpose of the clearinghouse to facilitate and disseminate practical tools and resources developed by local services to share learnings.

Further information can be found at the Clearinghouse Australia disease management association website.

Statewide ICDM Network

Primary Care Partnership staff working on integrated chronic disease management meet regularly at DH, 50 Lonsdale Street & VHA, Level 6, 136 Exhibition Street, Melbourne.

Meeting dates for 2011 are as follows:

• 9 Feb 2011 (VHA)
• 15 June 2011 (TBA)
• 10 Aug 2011 (DH)
• 16 Nov 2011 (DH)