Chronic disease: Better management of people with chronic disease in HealthOne NSW services

Chronic disease has a wide scope both in variety of conditions, and severity. It is important in service planning for chronic disease to consider not only population need but the capacity of organisations to deliver quality care in a sustainable manner.

The chronic disease management pyramid stratifies the population into stages of chronic disease. The requirements for care service provision intensify when addressing needs of those within level 1 and 2 of the pyramid. Planning the provision of care services should consider the resource intensity of the target population to ensure service sustainability.

Successfully achieving quality service provision for people with chronic disease may see demand arise from beyond the intended target population. Clinicians may seek to refer any of their patients that they perceive would benefit from planned care delivered by a multi-disciplinary team.

Discussion from the floor raised a number of important points:

• That co-location does not automatically or immediately bring integration.
• Effective information sharing is more significant than physical co-location, though this of course make information sharing at all levels easier.
• People can get very concerned about whether or not they were integrated and about systems and processes before they ask "what do we want to be able to do together?" A necessary first step is to consider what components is required for the optimal provision of care for people with chronic disease.
• Genuinely integrated care reduces the possibility of patients "falling through the cracks".
• Confidence in integration helps clinicians work together in a complementary manner. This confidence can reduce the need some clinicians feel to "do everything".

A crucial question for potential team members is 'what constitutes a team?' Exploring the roles within a team is important - understanding one another's skills and competencies, and preferred work styles. Well established multi-disciplinary team work involves a willingness to learn from one another.

Team building can take longer than people may expect and managing expectations is essential for managers and team members. Change management experts talk about four stages of team building 'forming, storming, norming and performing'. Recognising these stages and where a team is along this continuum can help a team reflect on its progress in team building.

It is important for clinicians establishing a multi-disciplinary team or coming into an established team to recognise that trust among clinicians is earned and that it may take time for particular skills and competencies to be recognised and utilised. Inservice sessions are one way of exchanging knowledge and skill within a team and building recognition for each member's particular strengths. Behaviour change counselling is an example of a skill that clinicians can share in a multi-disciplinary team providing chronic disease management.

Team care is dependent upon quality information exchange including case conferencing, shared care planning and informally sharing ideas about patient care.

Managing privacy obligations is an important requirement for HealthOne NSW services, but one that has the potential to interrupt the flow of patient information between care providers. There are a large number of privacy standards across different organisation, and this may reflect the variation in understanding of privacy requirements. In this environment, some services may opt for the 'lowest common denominator' approach to release of information, that is, unsure how much they can release, they release as little as possible.