INTEGRATED CHRONIC DISEASE MANAGEMENT
Aim
To share current information, trends and determine the strategies for work with our partner agencies to address chronic disease management in our region.
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Heartmoves - Chronic Disease Fitness Program at Horsham Aquatic Centre
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Our work focuses on:
- Supporting member agencies to meet the needs of people with chronic illness.
- Ensuring options for self management are available to people with chronic illness across the Wimmera PCP catchment.
- Assisting member agencies in workforce development.
- Linking closely with the PCP's work in Integrated Health Promotion and Service Coordination.
The Wimmera Primary Care Partnership recognises the impact of chronic illness on the people of the Wimmera, their carers, friends and the families of people living with chronic illness. Management of chronic illness needs to take a holistic approach to care and involves a range of disciplines in the client's care.
How are we doing this work?
The Wimmera Chronic Disease Reference Group was formed in July 2007 to plan and support the work of organisations in chronic disease management.
Key work that is occurring:
- Use of case studies to develop a whole of system awareness and client focus for Integrated Chronic Disease Management.
- A process to improve inter-sectoral respect and awareness of each others services.
- Active involvement and collaboration between member agencies in planning and implementation of local chronic disease management.
- A process to improve communication between health services and General Practice - leading to the development of GP engagement tools for chronic disease programs.
- Utilisation of 'position statements' to communicate key messages from each Wimmera Chronic Disease Reference group meeting to higher management levels within member agencies.
- Diabetes Working Group has developed a client held record and is currently being trialed. This client hand held record reinforces client at centre of care; keeps information of multiple providers in the same place; supports information sharing with clinicians and supports self management.
- Locally delivered training in self-management approaches: Flinders Model of Chronic Condition Management (August 2007) and Health Coaching (May 2008), Motivational Interviewing (2009), Self Management Approaches (2009).
- Self Management Mapping Survey - completed by organisations - analysis occurring by Department of Human Services (July 2008 & October 2009).
- Formation of the Intake/Service Access Working Group (October 2009).
For more information contact Donna Bridge on (03) 5362 1221.
Chronic Disease Reference Group Work
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