Disease Management Industry Overview by cpd60066

VIEWS: 9 PAGES: 16

Disease Management Industry Overview document sample

More Info
									         Integrated Chronic
        Disease Management

                                          Dianne Berryman
                                          Industry Advisor
                               Integrated Chronic Disease Management
                                        Primary Health Branch




Department of Human Services
Overview of ICDM


 1. Definition and Background



 2. Building blocks of ICDM
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.
Shifting the Impact of Chronic Disease
                                                       Current pattern of morbidity
                     Pattern of morbidity with prevention and disease management

 Morbidity                                                              Acute – eg. HARP
                                                Chronic disease
      15                                        management
                                                and self
                                                management

                                 Risk factor
                                 prevention &
      10                         management




        5




            0   10    20    30     40     50    60    70     80    90     100     110
                                                     Age
 LaTrobe University
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
Wagner Improving Chronic Care Model




• Underpinned by strong evidence
• Evaluations show improved client outcomes
                     Building Blocks
                        for ICDM




Department of Human Services
1. Partnership

a) Are we organised for success?
Leadership, governance, stakeholders, etc.

b) How far are we prepared to go?
2. Understanding consumer needs

• Most common (growing?) condition/s

• Barriers to service access

• Consult consumer representatives
3. Partnering with consumers

 • Involve consumers in planning

 • Support/resource consumer groups

 • Support consumers to be actively involved
   in their own care
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.
5. Self-management Support

• Training of service providers /
  clinicians
• Promote the use of validated self-
  management models
• Ongoing support of clinician change in
  practice
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
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
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
Further Resources

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

								
To top