INTEGRATED CHRONIC DISEASE MANAGEMENT
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. How is the Wimmera PCP doing this work? The Wimmera PCP formed the Wimmera Chronic Disease Reference Group in July 2007 and this group continues to progress work in ICDM. We meet bi-monthly 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. Key work that is occurring – click here to find out how we are doing this work
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