What is Integrated Chronic Disease Management?
People with chronic disease have a complex journey to manage. This journey can:
- involve accessing a range of health and community services
- be long-term
- cross boundaries of agencies and services and
- involve managing many symptoms
The aim of Integrated Chronic Disease Management (ICDM) is to improve the coordination of the health and community system so that people with a chronic condition receive effective care across the different stages of their disease that is responsive to their needs.
The Role of Primary Care Partnerships in ICDM
Primary Care Partnerships (PCP), as a voluntary alliance of agencies, are focused on facilitating service system integration between primary health care services and other agencies in delivering services to clients with chronic disease and on improving the client experience and outcomes. This includes supporting practice change that will lead to improved communication, referral and care planning. The PCP staff play a key role in supporting agencies in this work, particularly in facilitating partnership development, articulation of roles and responsibilities, planning and pathway development.
Chronic Disease Management – Wimmera
The Wimmera PCP formed the Wimmera Chronic Disease Network in July 2007 and this group continues to progress work in the chronic disease space. We meet quarterly and our focus is to improve the service system for clients with chronic conditions by using quality cycles and Service Coordination frameworks to place consumers at the centre of service delivery.
For more information please contact:
Kellie McMaster
Agency Liason Officer
Ph: 03 5362 1222 or email Kellie at kellie.m@grampianscommunityhealth.org.au
Wimmera Chronic Disease Network Case Studies
- 2010 – better coordination and care for clients with chronic conditions – working with GP’s
- 2011 – improving communication and care planning practice with health services and general practice
- 2012 – using continuous Quality Improvement to deliver care for chronic disease clients
- 2013 – patient perspective of multidisciplinary chronic care
- 2014 – streamlining initial needs identification for chronic and complex clients leads to care planning
- 2015 – playing the long quality game improves chronic disease outcomes for rural patients
Wimmera Chronic Disease Network Conference Papers
- Improving Communication with General Practice at Rural Northwest Health
- Improving Communication and Care Planning with Health Services and General Practice in the Wimmera
- Improving GP Communication, Referrals and Client Care at West Wimmera Health
- Improving Care Planning Practice using PDSA at Wimmera Health Care Group
- Improving Care Planning using PDSA at Dunmunkle Health
- Playing the Long Quality Game at WWHS Improves Chronic Disease Outcomes for Rural Patients
- Delivering Multi-Disciplinary Cardiac Rehabilitation in the Bush – the Wimmera HUB and Spoke Telehealth Model; Improving Access to Rural People
- Bringing Cardiac Rehabilitation to the Patient – the Wimmera HUB and Spoke Telehealth Model; Improving Access to Rural People