Integrated Chronic Disease Management Portfolio

Care for people with chronic disease usually involves multiple health care providers in multiple settings. To provide this care within an integrated system, health care providers must work collaboratively to coordinate and plan care and services. It requires a commitment by agencies to working together to achieve shared goals. In particular, people with chronic disease need a responsive, person-centred and effective system of care. The PCP will work to help achieve this for the Banyule Nillumbik area.
During 2001–2004 BNPCA auspiced a very successful pilot project called “Take the Pressure Down”: implementing a Self-Management and Hypertension Program in the Community. This project promoted co-ordinated and planned care, based on evidence of best practice along with care pathways including engagement of all players and early intervention and prevention of hypertension with a health promotion focus on physical activity and awareness of hypertension. During the project staff were trained in Better Health Self Management programs.
In 2006 Banyule Community Health Service was funded to implement an Early Intervention in Chronic Disease Initiative. Over the next three years a clear strategy for integrated chronic disease management throughout the catchment will be developed by utilizing all that has been learned from the previous work in chronic disease programs.
Progress in this Portfolio area has clear links with both Service Coordination (SC) and Integrated Health Promotion (IHP). Whilst SC will focus on creating a streamlined and coordinated service system for individuals who fall under its umbrella along with the development of a comprehensive assessment and care planning process; IHP will aim to infl uence entire populations to enhance their health and wellbeing through various capacity building strategies.
The following ICDM goals and objectives demonstrate that the fi rst year of activity will be directed towards the implementation and commencement of the Banyule EliCD initiative. The goals in this Portfolio will focus on facilitating service system integration and change management.
The following goals have been set for the next three years:
Goal 1: Develop an integrated approach in the use of self management across the catchment.
Goal 2: Ensure that suitable service coordination occurs for clients with chronic disease.
Goal 3: Expand the availability of early intervention in chronic disease initiatives across the catchment.