Connecting Care for Severe Chronic Disease Management Workshop
24th September 2009
Aims
To review experience in integrated chronic disease management models of care including:
- Models in Australia and overseas
- Key issues concerning stakeholder engagement
- Enhanced use of information and communication technology
To consider examples of integrated chronic disease management models of care including:
- Models in primary health care service settings, and connecting primary health care, sub acute care and acute care
- Models with particular reference to integrated chronic disease management for people with severe chronic disease
- To consider practical measures for implementing the new Severe Chronic Disease Management Program.
Presentations
Strategic Directions in Integrated Chronic Disease Management (CDM)
Overview
Dr Richard Matthews
Biography
Dr Richard Matthews is the Deputy Director-General of the Strategic Development Division at NSW Health. Until June 2007, Richard carried a dual role as Deputy Director-General and Chief Executive of Justice Health. He commenced his career in general practice and developed a special interest in drug and alcohol. He has worked for many years at St. Vincent’s Hospital Rankin Court Methadone Stabilisation Unit.
His association with Justice Health (previously known as Corrections Health Service) began in 1992 when he assumed responsibility for administration of the Methadone Maintenance Program. In 1993, he was appointed Director of Drug and Alcohol Services for Justice Health, in 1998 Director of Clinical Services, and Chief Executive Officer in 1999.
In his current role at NSW Health Dr Matthews has strategic planning responsibility for Statewide Services Development, Primary Health and Community Partnerships, Mental Health, Drug and Alcohol, Intergovernment and Funding Strategies, Chronic Disease and Rural Health initiatives.
Abstract
Overview of the key issues, drivers, planning for action, collaboration and the international experience Where we are now/where we are going – patient cohort opportunities, and population groups
The rate of people with chronic and complex disease is increasing rapidly, creating an enormous strain on hospitals and Emergency Departments which is financially unsustainable as the population ages, and does not lead to optimal health outcomes. The ‘Kaiser Permanente pyramid’ provides a useful method for service planning for people with chronic disease by combining risk-stratification with the appropriate level of care management.
The Severe Chronic Disease Management Program is a new program which will be rolled out over the next four years to deliver more effective health management for elderly people over 65 years and Aboriginal people over 45 years with chronic diseases. The Program will identify patient cohorts and commence enrolment of these patients on the program. Identification of the cohort will focus on those older people with Diabetes, Congestive Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease and Hypertension. In addition, the cohort for enrolment in this Program will ideally be significant users of the acute health care system, thereby providing an opportunity to impact on demand for hospitals and emergency services, and demonstrate the Program’s impact within a short period.
Patients in Post Acute Care
It is easy for chronic disease management programs to have a purely clinical focus. In many patients, particularly the frail and elderly, functional deficit from a variety of causes contributes to high health costs, poor outcomes and multiple hospital admissions. Much of the functional deficit requires non-clinical rather than clinical support. Consideration needs to be given to how we coordinate clinical care with home and aged care and other forms of support. Some of these programs – such as Community Acute / Post Acute Care (CAPAC), ComPacks (case managed packages of care), the Transitional Care Program, HACC services and Home Care services - and the opportunities they offer for coordination will be discussed.
(PDF format - 96 KB)Integrated Primary Health Care Models and CDM: Lessons Learnt
HealthOne perspective and the "Care West" proposal
Di O’Halloran
A general practitioner involved in health system change for more than a decade, Di is the Chair of the NSW General Practice Advisory Council, a member of the NSW Health Care Advisory Council and Co-Chair of the Primary and Community Health Advisory Committee.
Di also chairs WentWest: a large regional general practice training provider and one of only two such organisations to also manage divisional services. She has just stepped down after eight years as an RACGP Board member and Chair of the college’s NSW & ACT Faculty, and currently chairs the college’s National Presidential Task Force on Health System Reform.
Through NSW Health, Di is very involved in, and committed to, the evolution of HealthOne NSW, and sees this as a key strategy in building local partnerships between general practitioners, community health, other local services and the communities they serve. The development of a HealthOne community hub model in Mt Druitt is becoming a wonderful example of how such partnerships can form an effective local support platform for significantly disadvantaged patients, families and their careers while making health professionals’ lives more satisfying.
Louise Cowper
Louise Cowper is the Network Director Primary Care and Community Health in the Sydney West Area Health Service. Louise has responsibility for a range of multidisciplinary Community Health Services from metropolitan to rural settings across the area from Auburn to Lithgow. Louise has been instrumental in leading a significant period of service review and reform to align community health services to address the multiple challenges for the health system including strengthening care in the community for frail older people and people with chronic illness and the need to focus on early intervention in the early years to minimise the burden of disease impact in later years. Louise has a strong commitment to development of primary health care partnerships across a range of service settings in particular focusing on integrated service models involving GP’s and local community health services.
Louise currently has responsibility for the implementation of the three HealthOne NSW sites, with the Mt Druitt site being an early adopter of the concept and now demonstrating improved outcomes for clients whose care is being jointly managed through GP and Community Health clinical partnerships.
GP partnership Model, GP Collaboratives in a rural setting on the North Coast - Outlining the Model and the patients it supports
Tony Lembke
Tony Lembke is a GP in Alstonville, NSW, Australia. He is chair of the Northern Rivers General Practice Network and is Clinical Director of the Australian Primary Care Collaborative Program. This is a national program that has improved health outcomes by facilitating proactive and systematic care in general practice, and by increasing accessibility to primary care services. Tony has a strong interest in Health IMIT, having been Sydney University Medical School Donkey Kong Champion in 1983. He serves as a NEHTA clinical lead. In 2007 he was awarded the John Aloizos Medal for Outstanding Service to the Australian Divisions of General Practice. He currently is the NSW appointee to the board of the Australian General Practice Network. He is also the ever optimistic coach of the Lismore U15 Rugby team.
Abstract
Improved outcomes in chronic disease require better delivery of primary care. Practices participating in the Australian Primary Care Collaboratives have implemented better models to deliver more systematic and proactive care through general practice. This talk looks at some of the features of these models.
Integrated Care Models: Connected Care and Collaboration between the Acute, Sub-Acute and Primary Health Care Sectors
Diabetes Case Management as a Primary Health care iniative linking hospitals and GPs
Dr Greg Fulcher MB.BS.MD.FRACP.
Clinical Professor of Medicine, University Of Sydney; Director, The Department of Diabetes, Endocrinology and Metabolism, RNSH; Chairman, Diabetes Network, NSCCAHS; Member, Steering Committee, Diabetes Network GMCT Member AHAC, NCCAHS; Member GMCT Executive; Editorial Board “Diabetic Medicine”
Abstract
The redesign of clinical delivery systems is integral to providing quality care to patients with chronic disease, and specifically, to patients with diabetes. In addition to a traditional model of out-patient provided services, we established at RNSH in 2002, a diabetes complication assessment service (Sydney Diabetes Health Assessment Unit) to assist GPs who wished to be the major providers of care for their diabetic patients. This program was part of the Chronic Diseases initiative of the Department of Health. To optimize this service we added the role of diabetes case manager in 2008 and additionally worked to progress the development of appropriate information technology to underpin the clinical service. Thus over the past 7 years our service has evolved and now comprises 1) a strong support base of local general practices 2) a comprehensive health assessment by diabetes educators that informs a shared care plan 3) a diabetes case manager who co-ordinates the implementation of the plan and 4) an IT system that assists in audit and communication and assists in clinical decision making.
To date over a thousand patients have been examined in the Sydney Diabetes Health Assessment Unit and in the past 12 months, 300 of those patients have also been reviewed by the diabetes case manager. Early results indicate a significant improvement in glycaemic control, BP and lipids and importantly, care provided in the community with close liaison between the patient, the local medical practitioner, the case manager and the specialist hospital service.
Further development of the service includes the development of a patient empowerment programme, the identification of diabetic in-patients with post-discharge review in the unit and further refinement of the IT support base. The addition of a population health manager as per the Kaiser model will be explored.
Acute care, aged and chronic care, and prevention: the St Vincent’s Experience
Associate Professor Stephen Wilson
Associate Professor Wilson is appointed to St Vincent’s Hospital in Sydney with the Department of Rehabilitation Medicine and is the Director of the Population Health Program. His teaching and research interests include the development and provision of integrated community health care, multidisciplinary care and more effective medical communication. His PhD thesis focused on new models of multidisciplinary community health care. He has published papers on models of ambulatory care, multidisciplinary care and communication. His clinical responsibilities include Community Health activities with homeless and disadvantaged people.
Abstract
The current system for managing the health care of chronic disease patients lacks coordination and communication between providers. A new system may be constructed around three layers of care. The foundation is population health and prevention of disease and illness. The second involves coordinated care for established chronic disease management. This “health sandwich” is completed with a redesigned response to acute and subacute care. This will require new relationships and communication between community and hospital providers. The new system will necessitate increased patient responsibility for their own care with decision support for patients and providers.
The selection of patients is assisted by the understanding of hospital indicators for chronic disease diagnoses in local regions. Demographic and self care indicators may be more useful in identifying patients with multisystem conditions. The avoidance of hospital care for a registered patient with an acute on chronic episode will only be achieved hospital and community partnerships.
Patients in Post Acute Care - Transition Care and Sub Acute Care in Acute and Community Settings
Dr Richard Matthews
Identifying patients with severe chronic disease management in post acute care who would benefit from new health coaching and coordinated care in CDM Management
Information, Communications Technology and Chronic Disease Management
Care Navigator: The Westmead Experience
Kathleen Harrison
Abstract and Biography not available at this time
Technology for Patient Focussed Chronic Disease Management: Informatics, E Health, Telephony and Health Coaching
Dr Mukesh Haikerwal
Biography
Dr Mukesh Haikerwal is a practicing General Medical Practitioner, Commissioner to the National Health and Hospitals Reform Commission and Professor in the School of Medicine in the Faculty of Health Sciences at Flinders University in Adelaide, South Australia. He is currently working with the National e-Health Transition Authority (NEHTA) as the National Clinical Lead, leading a team of healthcare providers from multi disciplinary backgrounds, to assist in NEHTA’s liaison with the healthcare community and to provide input into the development of the NEHTA work program to deliver e-health for Australia. He was also the former head of the Federal Australian Medical Association (AMA) that is responsible for national policy development, lobbying with federal parliamentarians, co-ordinating activity across the AMA State entities and representing the AMA and its members nationally and internationally.
Abstract
Review of reform directions and the place of e-health as an enabler for enhanced health care delivery.
Designing Models for Integrated Information and Communication Technology for CDM in NSW
Mike Rillstone
Mike has been the A/ Chief Executive of Health Support Services (HSS) since June 2009. HSS delivers the NSW Health Shared Services Program including a range of business services and corporate and clinical ICT systems for eight Area Health Services and other public health organisations across NSW.
Previously, Mike was the Chief Information Officer for NSW Health – a position he was appointed to in January 2006. He has held the roles of Group Manager, New Zealand Health Information Service and Chief Advisor in Health Information and Technology for the New Zealand Ministry of Health.
Prior to these roles Mike led the public sector practice for Cap Gemini Ernst and Young in Sydney and has had worked extensively in the area of health Information Technology for the public and private sectors.
Mike has a strong interest in the implementation of clinical IT systems and particularly how these systems support changes in clinical practice.
As NSW Health CIO, Mike led the implementation of Health’s ICT strategy setting the direction and management for information and technology programs through Department of Health’s Strategic Information Management (SIM) Branch.
