Integrated Chronic Disease Management

The Victorian Context

Ruth Azzopardi, Department of Health

Why the continued focus??

Clients say:

• Care plans are important

• They want 'a point of contact‘

• Transitions within and between organisations) are not be well managed

Victorian Health Priorities 2012 - 2022

Issues:

uncoordinated and fragmented system

difficult to navigate for patients and practitioners

increasing levels of chronic disease, aging population, evolving technology and rising cost of services

system facing considerable challenges and will struggle to meet future needs

Victorian Health Priorities 2012 - 2022

Priorities:

Improve every Victorian’s health status and experience

Expand service, workforce, and system capacity • Expand capacity in community settings and homes, in

relation to primary medical care, early intervention and disease prevention, and chronic and complex disease management

• Build an interdisciplinary workforce to improve care coordination

Directions

• Prioritising services to high needs clients

• Early intervention

• Person centred care

• Support that assists people to better understand and manage their own health (self management, health literacy)

• Partnership to improve the coordination of care for people with chronic and complex needs

• Mixed models of care that include service funded through, private, public and MBS

Person Centred Care

Consumers:

• having an active role in their own health

• managing their ill health

• being a key part of the health care team

• informing the development of the health care service system

The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use

information in ways which promote and maintain good

health

Goal oriented care planning

Coordinated care

Who’s in charge

Delivery system design

Decision support tools

Self management support

Clinical information systems

Community

Access & Initial contact

INI

Assessment

Care planning

Care delivery

Monitoring & Review

Transition & Exit

Proactive recall

Health System

• Coordinated• Easy to navigate• Accessible• Intervention as early as possible

• Person Centred

A Framework to Get There

Agency Inter- agency care planning

Use of SCTT

E-referral Self management

support

CQI Clinical care protocols

MCHS

Melb Health

INW PCP Initiatives that address key improvements

INW PCP Initiatives that address key improvements

•Inter agency care planning (delivery system design) Doutta Galla CHS – Care planning tool developed by EIiCD Working Group to support interagency process and protocol

•Use of SCTT referral (clinical systems information) North Richmond CHS - Appointing an INI worker, modelling role & pathways

•E-referral (clinical information systems) Info exchange s2s used for NYCH – City of Yarra referrals

•Consent documentation (decision support) Melbourne Health - Audit of Medical Records Files July 2011

•Self management support provided to consumers and documented (self management support) North West Area Mental Health (in partnership with Moreland Hall) – Motivational interviewing rolled out through Advanced Clinician Training – Dual Diagnosis

•Quality improvement processes for ICDM (health care organisation) SVHM organisation wide formalised QI processes with annual quality plans for programs linked with area work plans. Accreditation under EQUIP standards.

•Clinical care protocols, pathways & decision tools for best practice (decision support) Merri CHS - Client Centred Care Project

INW PCP Initiatives that address key improvements

Final Messages

• Change• Effort• Support

…..the devil is in the