Chronic Disease Management
Chronic Disease management in the GVPCP
On 29 May 2008, member agencies representatives from across the Goulburn Valley Primary Care Partnership met to consider the integrated management of chronic disease in the Goulburn Valley. Representatives from the Department of Human Services Integrated Chronic Disease Management Primary Health Branch were active participants in the workshop.
The workshop purpose was to:
- Reflect on what is currently working, not working and what could be done better;
- Gain an understanding of what integrating chronic disease management across Goulburn Valley will require;
- Develop a short term vision for Goulburn Valley Primary Care Partnership for tackling an integrated approach to chronic disease management;
- Identify an approach for integrating chronic disease management across Goulburn Valley.
For a copy of the work shop summary click on the link below
GVPCP – Chronic Disease management forum Outcomes report
From the workshop a Vision for Chronic Disease management in the GVPCP was developed:
By 2010, Integrated Chronic Disease Management across the Goulburn Valley will mean we have a partnership between the consumer and service providers to deliver the right care in the right place at the right time.
Indicators of success in achieving this vision will be:
- All stakeholders including general practitioners are engaged;
- All stakeholders have an agreed common approach to consumer assessment and care planning;
- Appropriate direct client care is occurring in the right place at the right time;
- Information, resources and knowledge are being shared;
- There is equity in access and outcomes for consumers.
Lead agency Model
From those discussions a Lead agency model was developed the purpose of this was to increase membership capacity and deliver more viable outcomes for consumers and members. Click on the link below which outlines the objectives of the GVPCP lead agency Model
In partnership Goulburn Valley Health (GVH)and Goulburn valley Community Health Services (GVCHS) were selected as our lead agencies by the Executive Committee of the GVPCP. Below is a copy of their current work plan:
Lead Agency ICDM August 09 Work plan
The Lead agency Model is calling on member agencies to register for their project attached is documentation required for further information please contact GVH team via email at Tracey.Forster@gvhealth.org.au
Early Intervention in Chronic Disease (EIiCD )
EIiCD focuses upon community based early intervention services for people with chronic diseases. The initiative invests in both Community Health Services and Primary Care Partnerships.
Guiding principles
- Health care is person-centred care
- Consumers are active partners in the management of their chronic disease
- Consumers have increased choice and control
- The right care is provided at the right place and the right time
- Good health is proactively promoted
- Population subgroups of greatest need are targeted
- A whole of service system response is developed
EIiCD Target population
People with chronic disease (with or without complex needs) who may require hospitalisation in the medium to long term.
Services provided
Clients can access a range of health and medical services including community health funded integrated care coordination, nursing, allied health, counselling and self-management interventions.
For further general information and evaluations on the EIiCD project click on the link below
http://www.health.vic.gov.au/communityhealth/cdm/early_intervention.htm
EICD Shepparton: Chronic Conditions Self Management Program (CCSM)
What is the CCSM Program?
A partnership between Goulburn Valley Community Health Services and Goulburn Valley Health. The CCSM Program provides Health Coaching, Flinders Care Planning and the Better Health Self Management Course (BHSMC) with the aim to build individual’s ability to self manage.
What is the CCSM Program?
A partnership between Goulburn Valley Community Health Services and Goulburn Valley Health. The CCSM Program provides Health Coaching, Flinders Care Planning and the Better Health Self Management Course (BHSMC) with the aim to build individual’s ability to self manage.
Who is eligible?
- People who have been diagnosed with a chronic condition(s)
- And are above the age of 18 years
- People who do not reside in an aged care residential facility
NB. Carers of those who meet the above criteria are eligible for the BHSMC.
Who can benefit?
- People who can safely participate in self management interventions, to compliment their existing disease management strategies.
- People with stable mental health.
NB.People who are at imminent risk of hospitalisation will benefit from a referral at a later date.
How do I refer?
- Referrals will be accepted from: GP’s, Health Professionals and consumers (self referral)
- Referrals should be made using: SCTT Consumer Information and Summary and Referral OR Victorian Statewide Referral Form (VSRF)
- Feedback will be provided regarding acceptance of referral and consumer progress
Referrals can be mailed to either Community Health Service or GV Health, details over page.
What is the cost?
Gold Coin donation for each session of BHSMC. No cost for other services provided by the program.
Evidence based services provided by the CCSM Program
Health Coaching
One on one counselling style session, non directive, assists with identifying what is most important to the consumer and the barriers and enablers to them making change. Can assist in developing goals and self management plans.
Better Health Self Management Course (Stanford Model)
2.5hrs x 6 weeks group program, facilitated by two trained leaders. Involves information provision and discussions regarding symptom management, relaxation, breathing, eating and nutrition, fitness, coping with difficult emotions, problem solving, goal setting and communicating with health professionals. Ideal for building skills in self management.
Flinders Model of Chronic Care
One on one, structured interview style sessions using a number of tools to identify the consumer’s main problem, set goals and develop a care plan.
Contact details:
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Go to GV Community Health’s website: http://www.gvchs.com.au/ccsmp.html
Click in the following link CCSM: Information for HP July 2009
EIiCD Moira
This is a collaborative project with the partnership group including:
- Numurkah District Health Service,
- Nathalia District Hospital,
- Cobram District Health,
- Yarrawonga District Hospital and
- Moira Health Care Alliance.
The first year focus of the project is in the 4 key areas of:
- Effective and active engagement of Moira Shire GPs in EICD,
- Development of a consistent intake process,
- Minimum data collection and
- Staff Professional Development.
The project will aim to develop synergy amongst agencies in these 4 areas to ensure maximum benefit from EICD promotion, initiatives and programs. The greatest challenge will be working with agencies where different levels of service development and implementation exist and attempting to unify these processes into a coordinated format under EICD.
Please contact Vivienne Jeffery – Project Officer 5862 0560 for enquiries
Moira Shire Practioner Workshop - Click to Download the PowerPoint Presentaion
AHPACC Project
The Aboriginal Health Promotion and Chronic Care (AHPACC) Partnership aims to increase the access Indigenous people have to culturally appropriate health care. The AHPACC Partnership will support Community Health Services (CHSs) and Aboriginal Community Controlled Health Organisations (ACCHOs) to work collaboratively to improve health outcomes for Aboriginal Victorians with, or at risk of, chronic disease
AHPACC Vision
Aboriginal Victorians can access primary health care that is culturally respectful and addresses aspects of health including prevention, promotion and treatment, underpinned by principles of self-determination and collaboration, and endeavours to achieve a quality of life for Aboriginal people, equal with all other Victorians.
The vision of the AHPACC Partnership will be achieved through:
- Increased access to primary health care services by Aboriginal Victorians;
- Improved clinical service delivery, coordination and continuity of care, and support for chronic disease self-management approaches;
- Coordinated approaches to health promotion planning, implementation and evaluation by building upon existing programs;
- Increased capacity of CHSs in the provision of culturally sensitive services; and,
- Workforce development and organisational support for both Aboriginal and mainstream workers and organisations.
In the GVPCP catchment GV Community Health are working in partnership with the Rumbalara Co-operative:
Goulburn Valley Aboriginal Health Promotion and Chronic Care (AHPACC) Partnership
Aim: To ensure that members of the Goulburn Valley Aboriginal and Torres Strait Islander communities can access primary health care that is:
- culturally respectful
- addresses prevention, promotion and treatment
- underpinned by self determination and collaboration
- achieves equality for Aboriginal people
The AHPACC Partnership is a Victorian Government initiative developed through a consultative process between the Department of Human Services (DHS) and the Victorian Advisory Council on Koori Health (VACKH).
The Goulburn Valley AHPACC Partnership is between Rumbalara Aboriginal Cooperative and Goulburn Valley Community Health Service. Through their partnership these two agencies work collaboratively to improve health outcomes for Aboriginal Victorians, with or at risk of, chronic disease. Key focus areas include health systems development, health promotion, planning & implementation, access to primary health care services and chronic disease management programs.
Vision
Aboriginal Victorians can access primary health care that is culturally respectful and addresses aspects of health including prevention, promotion and treatment, underpinned by principles of self determination and collaboration, and endeavours to achieve a quality of life for Aboriginal people, equal with all other Victorians.
For further information about the GVCHS AHPACC project go to their website:
http://www.gvchs.com.au/koori_health_promotion.html
Other Documents
Self Management Mapping State wide report 0708 Final
Expanded Chronic Care Model Article
Other links
Dept of Human Services
DHS Information Clearing House
Health Coaching Support
Flinders University
Arthritis Victoria
Chronic Disease Self Management: Fact Sheet for PCP’s, DHS 2008
Self Management Mapping State wide Report
