Integrated Chronic Disease Management The Victorian Context Ruth Azzopardi, Department of Health
Mar 31, 2015
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