Integrated Chronic Disease Management

1. Integrated Chronic Disease Management Dianne Berryman Industry Advisor Integrated Chronic Disease Management Primary Health Branch

2. Overview of ICDM • Definition and Background • Building blocks of ICDM

3. 1. What is ICDM? The provision of person-centred care in which health services work with each other and with the client (and/or their carer) with a chronic illness to ensure coordination, consistency and continuity of care for clients over time and through the different stages of their condition.

4. Risk factor prevention & management Shifting the Impact of Chronic Disease Current pattern of morbidity Pattern of morbidity with prevention and disease management Morbidity Acute – eg. HARP Chronic disease management and self management 15 10 5 0 10 20 30 40 50 60 70 80 90 100 110 Age LaTrobe University

5. Background to ICDM in Victoria International Evidence Policy Documents Initiatives • HARP • 5x Integrated Disease Management Projects 2001-2004 • Sharing Health Care Initiatives 2001-2004 • EICD programs 2005 & 2006 • AHPACC • ABHI-PCIP (Divisions of GP) • Care in your Community

6. Wagner Improving Chronic Care Model • Underpinned by strong evidence • Evaluations show improved client outcomes

7. Building Blocks for ICDM

8. 1. Partnership a) Are we organised for success? Leadership, governance, stakeholders, etc. b) How far are we prepared to go?

9. 2. Understanding consumer needs • Most common (growing?) condition/s • Barriers to service access • Consult consumer representatives

10. 3. Partnering with consumers • Involve consumers in planning • Support/resource consumer groups • Support consumers to be actively involved in their own care

11. 4. Coordinated and Planned Care • Evidence base and best practice • Service coordination tools • Local care pathway development • Chronic care includes: systematic assessment, care plans, systematic follow up and review, multidisciplinary team.

12. 5. Self-management Support • Training of service providers / clinicians • Promote the use of validated self-management models • Ongoing support of clinician change in practice

13. 6. Health Promotion • Raise community awareness of chronic disease risk factors • Link to peak body health promotion activities • Risk factor screening • People with chronic disease still need to address risk factors

14. 7. Targeting Subgroups • Population health data • Information from local agencies • Plan appropriate interventions • Building on health promotion initiatives with at-risk and ‘hard to engage’ populations

15. 8. Planning for Success • Build on past success – SC, HP, etc? • Skills and experience of partners • Language – do we mean the same things • Outcomes and timelines • Communication back to/in organisations

16. Further Resources • ICDM Industry Advisors website (case studies, fact sheets, resources, links):www.health.vic.gov.au/communityhealth/cdm/ia.htm • Wagner / Improving Chronic Carewww.improvingchroniccare.org • Stanford Patient Education Research Centerhttp://patienteducation.stanford.edu/ • Flinders Modelhttp://som.flinders.edu.au/FUSA/CCTU/self_management.htm