What is Integrated Chronic Disease Management?

The Victorian Government Health Information website defines Integrated Chronic Disease Management as:
'Integrated Chronic Disease Management occurs when health services work together with the client (and /or their carer) with a chronic condition to improve their health and well being and quality of life. Those people with chronic disease receive responsive, person centered care over time through the different stages of disease progression.'
 

Integrated Chronic Disease Management  is based around the Wagner Chronic Care Model and 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. GP, podiatrist, physiotherapist, counsellor, dietitian, nurse, specialist, dentist, etc.)
• care that is provided over time through the stages of disease progression

Chronic disease is an illness, such as heart disease, asthma, or diabetes which is ongoing or recurring but is not caused by infection and is not passed on by contact. It is often not curable and needs to be managed over many years, and has significant impacts upon daily life. 

Chronic disease has a profound effect on the physical, emotional and mental wellbeing of individuals, often making it difficult to carry on with daily routines and relationships. Chronic disease, if not well managed will lead to complications. For example, diabetes can lead to amputations or kidney failure if not well managed. 

However chronic disease can be managed well with the help of a health care team, client self management support and the minimisation of lifestyle risks such as poor diet or low levels of physical activity.

Integrated Chronic Disease and the CHPCP
Some of the recent Integrated Chronic Disease work the CHPCP has been involved with includes - 

Early Intervention in Chronic Disease Projects
     - Ballarat - Health Independence Program at Ballarat Community Health Centre.
     - Hepburn - new program announced and planning underway with Hepburn Health Service.

Chronic Condition Self Management Project
    - Joint project with CHPCP, Ballarat District Nursing & Healthcare and Ballarat & District Division of General Practice in developing care coordination for newly diagnosed diabetics over 60 years.

Workforce Development
     - Health Coaching Training - 2 day training held 2008 with 23 staff attending.  
       To review evaluation - click here
     - Flinders Model Training
     - Commonwealth government application pending for self management training and agency support.

Self Management Mapping Results

This is the statewide data collated from the Self Management Mapping audit undertaken by PCPs in late 2007. The audit identified that while CHPCP has a number of trained staff in self management, barriers exist in organisational structures and GP Practice that impede the ability of workers to fully implement self management for their clients. 

Diabetes Steering Group
The CHPCP facilitates the Central Highlands Regional Diabetes Steering Group, this group consists of health providers and health professionals from agencies such as, Ballarat Health Services, Hepburn Health Service, St John of God Hospital, Hesse Rural Health, Djerriwarrh Health Service, Ballarat & District Division of General Practice, Ballarat Community Health Centre and Ballarat District Nursing and Healthcare.

For more information about the Diabetes Steering Group please click here.

For further information about Integrated Chronic Disease Management in CHPCP please contact Frances Riggs, Promary Health Care Coordinator, ph 03 5338 4773 or email icdm@chpcp.org

A range of resources, and research documents related to these areas is located in the Resources area of the website.

Useful Websites
Victorian Government Health Information - Chronic Disease Management
DHS - chronic disease webpage
Ballarat & District Division of General Practice Chronic Disease Website