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INTEGRATED CHRONIC DISEASE MANAGEMENT

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.


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  

 

 

For more information please contact: 


Donna Bridge
Agency Liason Officer
Ph: 03 5362 1221 or email
donna.b@grampianscommunityhealth.org.au

Case Study- Improving Communication with General Practice at West Wimmera Health Service- click here 

Case Study- Improving Communication and Care Planning with Health Services and General Practice in the Wimmera- click here 

Chronic Disease Reference Group Work
Improving Communication and Care Planning with 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
Improving Communication with General Practice at Rural Northwest Health

Chronic Disease Reference Group 1 Page Overview of Work - July 2007 to August 2008
Diabetes Mapping Forum Outcomes Report Oct 2007
Diabetes Self Management Program
DHS Member Agency Engagement Case Study - Wimmera PCP
Hospitals Admission Risk Program (HARP)
Wimmera Client Held Diabetes Record
Wimmera Client Held Diabetes Record - Information for Clients
Wimmera Client Held Diabetes Record - Information for Staff
Roadmap for people living in the Hindmarsh area with chronic disease.          
Roadmap for people living in the Yarriambiack area with chronic disease.
Roadmap for people living in the Horsham area with chronic disease.
Roadmap for people living in the West Wimmera area with chronic disease.

 

Useful Links:
Arthritis Foundation
Asthma Foundation
Australian General Practice Network
Department of Health and Ageing
Department of Health and Ageing Victoria
Diabetes Australia - Victoria
Heart Foundation
Diabetes Prevalence Map - Local Government Area


Reports/Resources:
Models of Self Management Support
Population Health Data Sources for ICDM Planning
Self Management Fact Sheet
Victorian Government Your Health Priorities
DHS Self Management Mapping
A Roadmap for People Living with Chronic Disease in Horsham
What is Self Management - DHS Workshop
Chronic Disease Self Management Training
Australian Disabetes Society/Australian Diabetes Educators Association Scientific Meetings 2008
General Practice Engagement in Integrated Chronic Disease Management
Evidence Based Guidelines and Clinical Pathways for ICDM Planning
Chronic Conditions Consumer Journeys Project:  Rural Consumers' Experiences of Chronic Conditions
 
Chronic Condition Self Management Guidelines for GPs (RACGP)
Guidelines for General Practitioners
Desktop Guide for General Practitioners
Guidelines for Nurses and Allied Health Professionals
Desktop Guide for Nurses and Allied Health Professionals
 
Life Expectancy at Birth:  Victoria 2002 - 2006
Victorian Ambulatory Care Sensitive Conditions Study

Burden of Disease - DALY Hindmarsh
Burden of Disease - DALY Horsham

Burden of Disease - DALY West Wimmera
Burden of Disease - DALY Yarriambiack


Burden of Disease - Top 50 causes Hindmarsh
Burden of Disease - Top 50 causes Horsham
Burden of Disease - Top 50 causes West Wimmera
Burden of Disease - Top 50 causes Yarriambiack
 

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