Integrated Chronic Disease Management

Overview

quality care

Coordinating chronic disease support

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 Integrated Chronic Disease Management (ICDM) Steering Committee was established to provide leadership and strategic oversight of the chronic disease programs and initiatives of our member organisations and agencies. The committee meets quarterly and its members are:

  • Brimbank City Council
  • DHS North & West Metropolitan Region (N&WMR)
  • Djerriwarrh Health Services
  • HealthWest Partnership
  • Hobsons Bay City Council
  • ISIS Primary Care
  • Maribyrnong City Council
  • Melton Shire Council
  • PivotWest
  • Royal District Nursing Service, Altona and Sunshine
  • Western Health
  • Western Region Health Centre
  • 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.

 

Early Intervention to Chronic Care