Following the evaluation of the Chronic Disease Management Program in 2015 a redesign process has been undertaken to align the Chronic Disease Management Program with the NSW Integrated Care Strategy. The new model, Integrated Care for Patients with Chronic Conditions reflects Commonwealth reforms and support equitable access, comprehensive evaluation and local flexibility to ensure the needs of individual patients can be met.
The Integrated Care for Patients with Chronic Conditions model strengthens and emphasises:
The model has been introduced to health services in stages over the past 12-18 months and will continue to adapt and be refined as new shared learning is developed overtime. This model aligns with the health care reforms underway in primary care, and the implementation of Commonwealths Health Care Homes model, supported by the recommendations in the Primary Health Care Advisory Group Report: Better Outcomes for People with Chronic and Complex Health Conditions
Integrated Care for Patients with Chronic Conditions:
The information collected in the patient identification and selection steps will help to inform the next steps for intervention support. The appropriate intervention is based on clinical judgment and patient goals, and is always in partnership with the patient. NSW has defined three integrated care interventions:
A patient-centred approach to goal-setting, active learning and self-management that guides, empowers and motivates an individual to change their behaviour. Health coaching programs support patients to modify their own behaviour, self-manage and monitor their chronic conditions and medications.
The role for care navigation is to facilitate access to services for the care of a patient, their carers and family for a defined episode of care. The aim of care navigation is to:
Deliberate person-centred organisation of patient care activities between providers to facilitate self-management, appropriate care, health outcomes and greater efficiency. Patients enrolled into the integrated care program are monitored and supported for the duration of the intervention. A key aim is to empower patients to self-manage, understand their illness, and seek additional support and intervention when required.