Integrated Chronic Disease Management
As the Primary Care Partnership for Melbourne’s western region, HealthWest Partnership brings together health and community organisations and agencies working with people who have chronic diseases in Brimbank, Hobsons Bay, Maribyrnong, Melton and Wyndham to coordinate chronic disease management and initiatives. By bringing organisations together to work collaboratively on tackling chronic disease, a more responsive, person-centred and effective system of care is being built to support early intervention and prevent complications and progression of chronic disease. The purpose of this work is to improve quality of life for people living with and at risk of chronic disease.
Chronic diseases make up more than 70 per cent of Australia's overall disease burden due to death, disability and diminished quality of life. Evidence suggests that people with chronic disease who participate in chronic disease management programs have a better quality of life, experience fewer complications and reduce their overall use of health care resources.
Integrated Chronic Disease Management involves:
- Planned and proactive care to keep people as well as possible.
- Empowering, systematic and coordinated care that includes regular screening, general practice (GP) recall and reminder systems, support for self-management and assistance to make lifestyle and behaviour changes.
- Care that is provided by a range of health services and practitioners, including GPs, podiatrists, physiotherapists, counsellors, dietitians, nurses, specialists and dentists.
- Care that is provided over time through the stages of disease progression.
HealthWest’s Health and Wellness Alliance in the West, which incorporates the Active Service Model steering group and Integrated Chronic Disease Management (ICDM) steering group, known as HWAW, provides leadership and strategic oversight of the chronic disease programs and initiatives of our member organisations and agencies. The alliance meets every two months and its members are:
- Arthritis Victoria
- Brimbank City Council
- Carers Victoria
- DHS North & West Metropolitan Region (N&WMR)
- Djerriwarrh Health Services
- HealthWest Partnership
- Hobsons Bay City Council
- ISIS Primary Care
- Maribyrnong City Council
- Melton City Council
- Mercy Health
- Macedon Ranges and North Western Melbourne Metropolitan Medicare Local (PivotWest)
- Royal District Nursing Service, Altona and Sunshine
- Western Health
- Western Region Health Centre
- Southwest Melbourne Medicare Local (Westgate GP Network)
- Wyndham City Council
Objectives and Activities
- Increase the capacity of member agencies to effectively address chronic disease through a planned, evidence-based and integrated approach.
- Develop effective strategies to reach people who have limited engagement with the health service system.
- Enhance service coordination.
- Improve health outcomes for clients and the community.
- Implement chronic disease self-management models based on evidence of best practice, and improve consumer involvement.
- Ensure that agencies’ client/patient base represents regional demography and community need, particularly groups at greater risk of developing chronic disease.
- Develop strategies to engage those most at risk of developing or experiencing progression of chronic disease.
- Give strategic advice on system redevelopment to build comprehensive client/patient needs identification, referral and case management links.
- Develop evaluation mechanisms for service system redevelopment and clinical intervention.
- Create a framework for securing additional funding or resources.
Case StudiesAs part of the 2010-2011 Department of Health reporting requirements, a case study was prepared which summarised the development of the Self Management Self Reflective Tool.
Chronic Care - Training Needs Analysis Toolkit (CC-TNA Toolkit)
In 2011 and 2012 the Deprtment of Health funded a project in association with the Statewide Integrated Chronic Disease Management PCP Network and in partnership with Inner East PCP and Deakin University which supported the development of a training needs analysis toolkit. This toolkit helps to assess the training needs for clinicians working with clients who have chronic disease. The toolkit can be accessed here.
Early Intervention in Chronic Disease
The Early Intervention in Chronic Disease (EICD) initiative is focused on community based early intervention services for people with chronic diseases. These services provide integrated care coordination and self-management interventions. Living Well is the EICD service in the west, funded for the local government areas of Maribyrnong and Brimbank and provided by Western Region Health Centre and ISIS Primary Care.
The guiding principles of EICD programs are:
- Health care is person-centred care
- Consumers are active partners in the management of their chronic disease
- Consumers have increased choice and control
- The right care is provided at the right place and the right time
- Good health is proactively promoted
- Population groups with the greatest need have access to early intervention and health promotion initiative
Self Management Special Interest Group Network (in partnership with the Chronic Illness Alliance)
This network is planning 4 forums in 2013. The first forum is being held on Monday February 25th. Registrations are currently being accepted for this forum which is focussing on mental health and chronic disease. For more information and to register click here.
The Department of Health (North & West Metropolitan Region) funded two EICD workforce development forums for 2010.
Chronic Disease and Mental Health Forum
This forum was held on Tuesday 12 October 2010 at Rydges Bell City in Preston. Chronic disease and mental health workers were provided with the opportunity for joint workforce development focused on the opportunities to improve care for people with a chronic disease and mental illness. The forum program is available here and presentations from guest speakers are available for downlad:
Setting the Scene – Pathways to Social Inclusion: Health Inequalities presented by Wendy Smith, Policy and Research Manager, VICSERV
North & West Metropolitan Region Context & Data presented by Matthew Hercus, Manager Primary Care, Department of Health N&WMR
Smoking and Mental Illness: The Elephant in the Room presented by Dr Sharon Lawn, Flinders University of South Australia
Implementing a Physical Health Strategy in a Mental Health Service presented by Bridget Organ, St Vincent’s Hospital
Use of the DASS21 Tool in assessment of EICD Clients presented by Lauren Hallyburton, ISIS Primary Care
Integrated First Response-A new model at Western Region Health Centre presented by Muriel Cummins, Community Mental Health Southwest
Metabolic Syndrome and Monitoring presented by Dr Basanth Kenchaiah, Northern Area Mental Health Service
Chronic Disease and CALD Communities Forum
This forum was held on Thursday 29 July 2010 at Darebin Arts & Entertainment Centre and provided an opportunity for chronic disease workers to build on their expertise and knowledge of working with culturally and linguistically diverse communities. Presentations from guest speakers are available for download:
Overview of Data for North and West Metropolitan Region presented by Matthew Hercus, Manager Primary Care, Department of Health, North and West Metropolitan Region
Overview of EICD Program at Darebin Community Health presented by Carolyn Hines, Manager Chronic & Complex Care, Darebin Community Health
Cultural Integrity in Health Service Provision presented by Michal Morris, Executive Manger, Centre for Culture, Ethnicity and Health
Cultural Responsiveness in Mental Health Service Provision presented by Tymur Hussein, Clinical Care Manager, Lighthouse Foundation
Positive Ageing Self-Management in Chronic Disease presented by Dr. Christine Walker, Chronic Illness Alliance