Integrated Chronic Disease Management - Documents

BNPCA agencies have been working together to achieve a streamlined referral framework to their chronic disease programs. See the attached files to read about the work of the Chronic Disease Collaborative, and also a copy of the brochures: one for GPs and the other for community members.

This report outlines the risk factors for, and prevalence of, chronic disease in the catchment and has been prepared under the direction of the Chronic Disease Collaborative. It draws together information from DHS hospital and community data, ABS statistics and General Practice data and alo provides detailed profiling of a number of key chronic diseases that are of high prevalence, and/or impace significantly on emergency presentations for the catchment.

The BNPCA Chronic Disease Collaborative commenced in Feb 2009 with representative from agencies in the catchment who provide chronic disease programs. This Report showcases the work of the Collaborative in its first year, including a referral framework to simplify the communities and GPs understanding of the chronic disease programs that are available and how to access them. Use the link to obtain a full copy of the Report.

This report was developed for the Banyule Nillumbik Primary Care Alliance, Chronic Disease Collaborative A study of clients accessing health services for a chronic disease was undertaken. Initially the central concepts of self management and service coordination are described. The processes of the study and the selection of interviewees are explained. The results of the interviews are detailed and discussed and finally recommendations arising from the findings of the study are made.

The Self Management Workshop held on Wed. 12th Nov 2008 for health service managers in Banyule and Nillum bik focusing on changes needed at an organisational level to support practitioners embed self management into their practice.

The Minutes of the Chronic Disease Collaborative held in August 2008.

This is the statewide data collated from the self management mapping exercise undertaken by PCPs in late 2007.

This is the report of a research project that was a collaboration between three Melbourne-based Community Health Services: Knox, MonashLink and Darebin Community Health Services with the Department of Health Science at Monash University. Staff from the Department of Health Science undertook the research which was funded by a grant from the Helen Macpherson Smith Trust. The study aimed to identify changes to management and care practices within and across organisations, and how individual health workers can further develop the necessary skills that support improvements in care for people with chronic medical conditions within Victorian Community Health Services. The qualitative research methods used included a review of relevant published literature, focus groups and interviews with key informants, document review and a consultation workshop. The Wagner model was used as a benchmark to assess the kinds of changes that were the centre of interest to this study. The report then, is about internal processes in those three CHS organisations that were developed through the establishment of their EliCD programs as well as the broader system change that was needed to develop integrated and multidisciplinary care. The project found that change necessarily occurred at three levels: · The practitioner, · The organisation, and · The broader service system. All levels of change are essential for effectiveness and sustainability of the EliCD.

Using concrete examples, this study translates the concept of the Chronic Care Model (and associated systems view) into practical application in Australian Indigenous primary care settings. This approach proved to be useful in understanding the quality of primary care systems for prevention and management of chronic illness. Further refinement of the systems should focus on both increasing human and financial resources and improving mangement practice.

A recent article published by the King’s Fund in London, reviewed the evidence base for the effectiveness of health behaviour interventions that target low-income groups, with the aim of reducing smoking, unhealthy eating, or increasing physical activity. One of the premises of the review was that “reducing health inequalities depends on developing interventions to increase health behaviours that are differentially effective in favour of those from disadvantaged backgrounds or target socially disadvantaged groups”. After an extensive screening process the review was based on 17 papers that fulfilled the criteria set by the researchers. The review highlighted two suggestive findings: • More focused interventions involving a small set of techniques may be more effective than interventions combining a large number of different techniques; which highlights the need to monitor the fidelity of intervention delivery. • The most common techniques (providing information and facilitating goal-setting) may be helpful for low-income groups. The two sets of techniques may be working additively, in that providing information about the benefits of changing behaviour may increase peopoe’s motivation to change, while helping people to form specific, realistic goals help people to translate motivation into action. The paper concludes that reducing health inequalities needs increased investment in research into behavioural interventions for disadvantaged groups. Use the link below to obtain a full copy of the article.

This paper discusses options for prorgram reform and re-alignment to improve chronic disease prevention and management in the Australian primary health care sector. It is structured in three sections (i) background and best practice in chronic disease management (ii) current chronic disease management programs in Austrlia, and (iii) systen and funding reform options.

The powerpoint presentation given at the "Improving Chronic Disease" Workshop held on 28th Feb. 2008.

This is the powerpoint presentation given by Marie Gill at the recent "Improving Chronic Disease" Workshop held on 28th Feb. 2008

The BNPCA Strategic Partnership Group has agreed to this ICDM Strategic Statement of Intent following a process of consultation with agencies, consideration of current models of chronic disease management and the DHS reporting requirements.

Integrated Chronic Disease Management Discussion Paper prepared for BNPCA Strategic Partnership Group meeting discussion October 2008. The paper is based on the current models of chronic disease care and the series of consultations undertaken with BNPCA agenices involved in the care of people with chronic disease. From this discussion an ICDM Strategic Statement of Intent was drafted and agreed upon, and now forms the basis of the BNPCA approach to Integrated Chronic Disease Management work in the catchment.

Summary of Chronic Disease Models of Care prepared for consideration of the BNPCA Strategic Partnership Group )ct. 2007

This document summarises the outcomes of a series of consultations undertaken with key BNPCA Agencies around Chronic Disease in Sept. 2007.

This documentfrom the UK and launched in January 2008 updates the first compendium of information on LTCs, published in May 2004. It will further inform all those who are involved in both commissioning and providing care and support services for people with Long Term Conditions (LTCs). It focuses on the outcomes that people with LTCs said that they wanted from services and describes how more effective management of LTCs in a number of local communities is delivering high-quality and personalised care. Finally, it summarises the key systems and levers that are crucial to driving forward further improvements in care for people with LTCs.

This report documents the Banyule/Nillumbik Primary Care Alliance’s (BNPCA) Hypertension IDM Project in relation to co-ordinated and planned care of consumers with hypertension, based on evidence of best practice. It outlines the key initiatives of the strategy as well as the effectiveness of the various initiatives in achieving anticipated objectives. The report also presents key lessons learnt and describes what has worked, and has not, in regard to co-ordinated and planned care of consumers with hypertension.

The evaluation of the BNPCA Hypertension Project Consumer Reference Group (CRG) has been made possible due to the support of the Project Team and enthusiasm of the CRG. Please click on the heading for the full report.

Background to the Internal Evaluation The Banyule Nillumbik Primary Care Alliance (BNPCA) Hypertension Integrated Disease Management (IDM) Project, also known as “Take the Pressure Down”, is a three-year pilot Project funded by the Department of Human Services (DHS), as part of the Primary Care Partnership Strategy. The goal of this Project is to improve health outcomes and quality of life for consumers with, or at risk of, hypertension in the Local Government areas of Banyule and Nillumbik. Please click on the heading for the full report.

This report documents the implementation of the GP Engagement Strategy, of the Banyule/Nillumbik Primary Care Alliance Hypertension IDM Project. It outlines the key initiatives of the strategy and the effectiveness of these in achieving the anticipated objectives. The report will also present key lessons learnt and describe what has worked or has not in regard to engaging GPs in this particular Project.

This report documents the Banyule/Nillumbik Primary Care Alliance’s (BNPCA) Hypertension IDM Project in relation to Self-Management for consumers with high blood pressure . It outlines the key initiatives of the strategy and the effectiveness of the various initiatives in achieving the anticipated objectives. The report also presents key lesson learnt and describes what has worked and what has not in regard to Self-Management Programs for consumers with high blood pressure.

This report documents the Banyule Nillumbik Primary Care Alliance (BNPCA) Hypertension IDM Project in relation to sustainable partnerships. It outlines the key initiatives of the strategy and assesses the effectiveness of the various initiatives in achieving the anticipated objectives. The report also presents key lessons learnt and describes what has worked or not in regard to sustainable partnerships.

Project findings for the Hypertension Integrated Disease Management Program

Summary of project findings for the Hypertension Integrated Disease Management Program.

Better Health Self Management Programs make a difference!! Preliminary results are in from the “Take the Pressure Down” Better Health Self Management programs (BHSMP)! As part of the “Take the Pressure Down” external evaluation, telephone surveys were conducted 6 months post program completion with participants from the first 8 programs. 47 participants consented to be interviewed. Majority of participants reported positive effects on health and improved ability to manage blood pressure Congratulations to the local leaders of the programs with 98% of consumers very satisfied with the way the leaders interacted with them. Further evaluation of the programs is continuing and final results will be reported in December 2003. For comments or enquires about these results please contact Marie Gill on 9457 9849 marie.gill@banyule.vic.gov.au. Attachment: Please click the above link for more detailed presentation of findings

Kate Lorig of founder of the Stanford University Better Health Self Management Programs facilitated a 2 day DHS forum in July. Marie Gill presented the IDM project focusing on recruitment strategies. Kate Lorig was very interested in the project in particular the data on recruitment and ask for a copy of the presentation to present back at Stanford. Kate encouraged the project to publish on our experiences.

Late last year a number of interviews and focus groups were run by the project. The purpose was to gain a better understanding of people's perception of high blood pressure, what issues were concerning them most about having high blood pressure and what type of program they felt may be able to help them deal with these issues. The findings have now been collated and the final report completed. The information provides direction for the ongoing planning of the program. The report contains a wealth of valuable information that could be useful for anyone planning programs for people with chronic health problems or community consultation.