Knox Improving Chronic Care Project The preparations required toimplement an effectivechronic diseas

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Knox Improving Chronic Care ProjectThe
preparations required to implement an
effective chronic disease program Kate Gilbert,
Chronic Disease Project Manager
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The Early Intervention in Chronic Disease
Initiative
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Scope of EIiCD

• Local systems and organisational development
• links with GPs (referral systems, care planning,
  team care arrangements)
• internal assessment tools, referral processes,
  prioritisation, self-management training
• support neighbouring CHSs
• Service delivery
• new clinical areas to respond to community
• key workers/named contacts
• self-management interventions/groups
• psychosocial / psychology
• 400,000 per year recurrent 167,000
  establishment

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Identifying target groups and priorities
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Consultation Timeline
Client-specific
Internal
GPs and other external stakeholders
Implem. Planning Pres. to DHS
Preliminary consultation local consumer groups
Key Stakeholders Forum
Collect Data Prevalence
Dental Service Chronic Disease Audit
OCTOBER
Convene Internal Reference Group
Mapping self-management interventions
Internal Chronic Disease Screening Exercise
Internal Client Sat. Survey
GP Phone Interviews
4 x Consumer Focus Groups Facilitated by Chronic
Illness Alliance
NOVEMBER
Implem- entation Plan to DHS
Consumer Focus Groups continued
DECEMBER
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• PHIDU - Population health profiles by Division of
  GP www.publichealth.gov.au
• Department of Human Services (2006). Ambulatory
  Care sensitive conditions 2004-05 update by
  Region.
• Burden of Disease - Disability Adjusted Life
  Years http//www.aihw.gov.au/cdarf/index.cfm
• HARP Local hospital admission data
• Local Council, Social Researcher

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Number of people in Knox (estimated) Reference
PHIDU. (2005) Population health profile of the
Knox Division of General Practice. Population
Profile Series No. 50. Public Health Information
Development Unit (PHIDU), Adelaide.
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Summary
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Chronic Disease in Knox

• Chronic Respiratory Diseases (COPD etc) - most
  prevalent chronic condition in Knox, even when
  asthma not counted
• Chronic Respiratory Diseases and Asthma -
  prevalence is gt10 above Australian average rate
  in north of Knox, and 5-10 above in south Knox
• When comparing chronic diseases
• Cardiovascular disease - greatest contributor to
  premature mortality and DALYs
• Diabetes - leading cause of preventable hospital
  admissions (Ambulatory Care Sensitive Admissions
  Study)
• Asthma highest cause of ED admissions in Knox

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One Day Snapshot Dental Clients
Which chronic conditions did the clients have?
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1 week 252 clients, 95 with chronic disease
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Is there anything we can do in . arthritis?
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Knox Target Groups

• Respiratory Disease gt Newly-diagnosed COPD
• Diabetesgt Type 2 diabetes Insulin Initiation
• Musculoskeletal gt Osteoarthritis Pathway
• Heart Disease gt Cardiac Rehabilitation

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Further findings after target groups determined
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Overview of Knox population
Mapping self-management interventions in the
Outer East
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Nature

• Generic/Evidence-based/Stanford model/ Better
  Health Self-Management 2
• Disease-specific
• MSK 8
• Cardiac 5
• Pulmonary rehabilitation 3
• Diabetes education 5
• Cancer 2
• Multiple sclerosis 1
• Weight loss 2

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Consumer involvement

• Focus Groups CIA
• Client Satisfaction Survey piggy back
• Reference Group consumer reps
• Community resources and linkages
• Informal local support groups
• Establishing partnership arrangements
• Delegated Community expert on staff
• Pathways ongoing support

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Cardiac Rehab Phase 3
Newly-diagnosed COPD
Type 2 Diabetes Insulin Initiation
Osteoarthritis Hip or Knee
EI Referrals to HARP
Spirometry services / GPs Angliss Rehab , HARP
GPs (existing referral stream)
KCHS Case-finding and internal referral
Angliss Hospital and GPs (existing referrals)
Eastern HARP ACCESS
Target Groups Referral Sources 1s YEAR
Review assessments already completed to avoid
duplication
Assume existing clients already had SCTT etc
KCHS INTAKE 1. SCTT 2. CDM introduction 3. Key
Worker identification
Allocate to Key worker
Psychologist case reviewand treat directly or
extra support to key worker
GP Intro Clinical data for evaluation
Mental health condition identified
Assessment inc. Partners in Health Scale,
Baseline Evaluation
Individual services Dental, Physio, OT, Podiatry,
Psychology, Counselling Diabetes Ed
Individualised Care Plan Flinders Goal Setting
Evidence Based Pathways
GP Detail Care Plan
Patient-held record
Community linkages Physical Activity,
Socialisation support, Lifestyle management,
Psychosocial support, Self-help groups
Follow-up Telephone coaching or individual
consults
Group programs Stanford course, Pulmonary rehab,
DAFNE Diabetes education, Falls prevention,
Tai-Chi for arthritis, CVD Phase 3, etc.
GP Revisions to Care Plan or 6 months
Scheduled Recall and Review 6-monthly
evaluation surveys