Integrated Chronic Disease Management

About Integrated Chronic Disease Management (ICDM)

Since 2006-07, all PCPs have received recurrent funding for ICDM which has become a key deliverable for all PCPs. It is recognised that ICDM work, like Service Coordination, is incremental and builds on partnership, service coordination and integrated health promotion foundations that have been embedded over the past 8 years. The funding acknowledges that PCPs play an important role in bringing agencies together to develop systems that support a coordinated approach to the planning and delivery of services for clients with chronic disease. ICDM initiatives are aimed at providing planned, managed and proactive care for people with chronic disease by providing more community based health services and providing services within an integrated health care system. More information regarding the initiative can be found in the Revised Chronic Disease Management Program Guidelines for Primary Care Partnerships and Primary Health Care Services

Integrated Chronic Disease Management is 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.

The Primary Health Branch of the Department of Human Services has endorsed the Wagner Model for Improving Chronic Care as the model to inform and guide service system redesign required to support people with chronic disease. The Wagner model provides a framework that helps identify the systems changes (within primary health care services and across the service system) that are necessary to improve the coordination of care for people with chronic disease. Taking a systems approach is important to ensure the delivery of proactive and integrated client centred care.

The model has six interdependent elements for improving chronic care which include:

Community	resources and activities that provide ongoing support for people with chronic disease/s.
Health systems	support prepared and proactive practice teams.
Self-management support	empowers and prepares clients to manage their health and health care.
Delivery system design	assist care teams to deliver systematic, effective, efficient clinical care and self-management support.
Decision support	including design, systems and tools to ensure clinical care is consistent with evidence-based guidelines.
Clinical information systems	including data systems that provide information about the client population, reminders for review and recall, and monitor the performance of care teams.

ICDM in Campaspe

Over the past 3 years ICDM work in Campaspe has focussed on;

Campaspe wide mapping of chronic disease interventions and services and self-management activities, identifying Diabetes as priority work area.
Facilitated professional development opportunities and agency support for self-management interventions such as;

Flinders Model of Chronic Condition Self-Management
Stanford University Better Health Self-Management Leader training

Development of a member agency agreement Self-Management Roles and Responsibilities.
Facilitated GP and Allied Health Networking evenings focussing on care planning and MBS items.

This work will progress with the 2009-2012 Strategic Plan prioritising Diabetes as a major focus and identifying the following opportunities;

Implementation of regional diabetes pathway.
e-communication.
ICDM with indigenous and hard to reach groups
Optimising links to IHP and prevention strategies.
Workforce capacity building.